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World Blindness 
and its Prevention 


Volume 4 




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World Blindness 
and its Prevention 

Volume 4 


Edited by 

Carl Kupfer, m.d., and Terrence Gillen, m.a., m.b.a. 



INTERNATIONAL AGENCY FOR THE 
PREVENTION OF BLINDNESS 














































At least 80 percent of all cases of blindness in the 
world can be considered avoidable — that is, they 
could have been prevented or they could be cured 
by using available and locally appropriate tech- 
nology. The International Agency for the Preven- 
tion of Blindness (IAPB), with its national and 
international partners, seeks to reduce global 
blindness by increasing awareness of this problem 
among the people of the world and their govern- 
ments, by encouraging financial and manpower 
support of blindness prevention programs world- 
wide, and by promoting the development of suc- 
cessful prevention programs that employ locally 
appropriate and cost-effective technology. 


Digitized by the Internet Archive 
in 2016 


https://archive.org/details/worldblindnessit04edit 


Contents 


Preface xv 

President’s Message xvii 

Dr. Carl Kupfer 

Welcome Message xix 

Dr. A.K. Gikonyo 

PART 1: Opening Ceremony 

1 Opening Remarks 3 

Dr. Carl Kupfer 

2 Welcome Address 5 

Mr. Samuel K. Toro re i 

3 Remarks 7 

Dr. Akira Nakajima 

4 Remarks 9 

Mr. Alan W. Johns 

5 Inaugural Address 11 

Hon. Mwai Kibaki 

6 Vote of Thanks and Affirmation 15 

Dr. Moses C. Chirambo 

7 Keynote Address 17 

Dr. Bjorn Thylefors 

PART 2: Plenary Session I — National Programs in Africa 

1 National Program Development: East and 

Central Africa 27 

Dr. Moses C. Chirambo 

vii 


viii Contents 


2 National Program Development: Ethiopia 29 

Dr. Paw l os Quana’a 

3 National Program Development: The Gambia, including 

Demographic and Manpower Considerations 31 

Dr Hannah B. Faal 

4 WHO Technical Cooperation in Africa, 

a Situation Analysis 35 

Dr T. Tukai 

5 National Program Development: 

Resources Mobilization and Management 41 

Dr K. Kagame 


PART 3: Plenary Session II — IAPB Regional Progress Reports 


1 Regional Progress Report: East, 

Central, and Southern Africa 45 

Dr Moses C. Chirambo 

2 Regional Progress Report: West Africa 49 

Drs. Daniel Etya’ale and Nicolas Toufic 

3 Regional Progress Report: Peru, Bolivia, Ecuador, 

Colombia, and Venezuela 53 

Dr Francisco Contreras 

4 Regional Progress Report: Argentina, Uruguay, 

Paraguay, and Chile 55 

Dr Eugenio Maul 

5 Regional Progress Report: Central America 59 

Dr Fernando Beltranena 

6 Regional Progress Report: North America 65 

Mrs. Virginia Boyce and Mr. John M. Palmer ; III 

7 Regional Progress Report: Eastern Mediterranean 67 

Sheikh Abdullah M. Al-Ghanim 

8 Regional Progress Report: Europe 77 

Gen. Marcel Chovet 

9 Regional Progress Report: South-East Asia 79 

Dr. R. Pararajasegaram 


Contents ix 


10 Regional Progress Report: India 85 

Prof. S.R.K. Malik 

11 Regional Progress Report: India, Bangladesh, Pakistan, 

and Sri Lanka 97 

Dr. Rajendra Vyas 

12 Regional Progress Report: Western Pacific 101 

Drs. Frank Billson , Kazuichi Konyama, 

and Lim Kuang Hui 

PART 4: Plenary Session III — Sustainable Manpower 
Development for Blindness Prevention 

1 Ophthalmic Manpower in Sub-Saharan Africa 115 

Dr. Allen Foster 

2 Training Doctors in Community Ophthalmology 119 

Dr. Rabiul Husain 

3 Sustainable Manpower Development for 

Blindness Prevention 123 

Dr. Moses C. Chirambo 

4 Sustainable Manpower Development for 

Blindness Prevention: Nepal 1981-90 125 

Dr. G.P. Pokharel 

5 Development of Management Personnel 

in Blindness Prevention 129 

Mr. R.D. Thulasiraj 

6 Management of an Eye-Care Program in a 

Developing Country 135 

Mr. Samuel K. Tororei 

PART 5: Plenary Session IV— New Developments 

in the Control of Major Causes of Blindness 

1 Developments in the Control of Cataract: 

Epidemiology and Clinical Research 149 

Prof. Gordon J. Johnson 


x Contents 


2 Economic Aspects of Cataract Blindness 157 

Dr. Michael F Drummond 

3 Update: Xerophthalmia, Keratomalacia, and 

Child Mortality including Measles 171 

Dr Barbara A. Underwood 

4 Assessment Methodologies for Xerophthalmia, 
Keratomalacia, and Child Mortality including Measles . 177 
Dr Emorn Udomkesmalee 

5 Update: Onchocerciasis 181 

Dr Adenike Abiose 

6 Use of Ivermectin in Onchocerciasis Control 189 

Drs. K.Y. Dadzie, G. De Sole , and J. Remme 

7 Organization of a Trachoma-Control Program 

in Africa, with Special Emphasis on Kenya 193 

Prof. Henry S. Adala 

8 Low-Cost Spectacles 199 

Dr. Francisco Contreras 

9 Providing Low-Cost Spectacles and Eye Medications . . 201 
Dr. Joseph Taylor 

10 Use of Portable YAG Laser to Treat Glaucoma 205 

Dr. Henry S. Newland 

11 Eye-Health Education and Social Marketing 209 

Dr. (Mrs.) Gopa Kothari 

12 Management Issues in Primary Eye-Care 

Training Programs 215 

Ms. Victoria M. Sheffield 

PART 6: Plenary Session V— Sustainable National 
Program Development 

1 Starting a National Committee for Prevention 

of Blindness 221 

Dr. Lincoln Agaba 

2 Raising Funds to Develop a National Program 225 

Dr. R.P. Pokhrel 


Contents xi 


3 Major Challenges and Priorities for the 

Delivery of Eye-Care Services 233 

Mr. K.S. Gupta 

4 The Importance of Government Commitment in 

Developing a Sustainable National Program 237 

Dr Francisco Contreras 

5 Why Governments Commit Themselves to Starting 

an Eye-Care or Prevention of Blindness Program 239 

Dr Fusun Sayek 

6 WHO Technical Cooperation for a National Program 

for the Prevention of Blindness 243 

Dr A.D. Negrel 

7 The Role of the Network of Non-Governmental 
Organizations in Starting and Developing 

Sustainable National Programs 249 

Mr Kevin Carey 

8 Current Activities of Non-Governmental Organizations 

in Prevention of Blindness and Eye-Care Programs ... 253 
Dr A. Hardenberg 

9 The Role of Non-Governmental Organizations in the 

Development of a Sustainable National Program 257 

Mr John M. Palmer, III 

10 The Role of an African National NGO in the 

Development of a Sustainable National Program 261 

Mr Michael A. Dunsford 

11 The Role of an Asian National NGO in the 

Development of a Sustainable National Program 267 

Mr K.S. Gupta 

12 The Role of an International NGO in the 

Development of a Sustainable National Program 273 

Dr. A.T. Jenkyns 

13 Corporate Interaction Relating to Future Prevention 

of Blindness Programs 275 

Dr. J. Gmunder 


xii Contents 


14 Challenges and Priorities for the Delivery 

of Eye Care 279 

Dr. G. Venkataswamy 

15 Appropriate Technology for Eye Care 285 

Dr. G. Venkataswamy 

16 Monitoring and Evaluation of National Programs .... 289 
Dr. R. Pararajasegaram 

PART 7: Plenary Session VI — IAPB Business Meeting 

1 Outgoing President’s Address 295 

Dr. Carl Kupfer 

2 Incoming President’s Address 299 

Mr. Alan W. Johns 

PART 8: Workshop Sessions 

1 First Workshop Session — Manpower Development .... 303 
Prof. Gordon J. Johnson 

2 Second Workshop Session — Delivery of Specific 

Eye-Care Services 309 

Ms. Victoria M. Sheffield 

3 Third Workshop Session — Major Challenges and 

Priorities for the Delivery of Eye-Care Services 315 

Anglophone Report— Dr. Bjorn Thylefors 
Francophone Report— Dr. Patrick Quequiner 

4 Fourth Workshop Session — Essential Characteristics 

of a Model Self-Sustaining Program 321 

Mr. Kevin Carey 

PART 9: Banquet and Awards Ceremony 

1 IAPB Lifetime Awards presented at the 
Fourth General Assembly 325 


Contents xiii 


PART 10: Appendices 

Appendix A National Delegates to the 

Fourth General Assembly 331 

Appendix B World Health Organization Regional Offices, 
Collaborating Centers for the Prevention of 
Blindness, and Member Nations by Region . 335 

Appendix C IAPB Leadership 1990-94 341 

Appendix D Constitution of the International Agency 

for the Prevention of Blindness 345 

Appendix E IAPB Membership Criteria 359 

Appendix F A Brief Overview of the Global Program 

for the Prevention of Blindness 361 

Carl Kupfer, M.D. 

Appendix G A Brief Review of Milestones in the Global 

Program for the Prevention of Blindness . . . 375 


PART 11: Index 


389 


























































Preface 


The Fourth General Assembly of the IAPB was held in Nairobi, 
Kenya, 11-16 November 1990. More than 400 ophthalmologists, 
public health workers, managers, and others in the prevention of 
blindness field traveled from over 70 countries to the Kenyatta In- 
ternational Conference Centre. National prevention of blindness 
committees from 60 countries were represented by 113 people at the 
Business Meeting. In addition, over a dozen non-governmental 
organizations and private corporations staffed booths that displayed 
their services and products. 

The theme of the meeting, “Sustainable Strategies — Agenda for 
the 1990s”, was discussed at the six plenary sessions and four 
workshop sessions by 86 designated speakers and panelists, plus 
scores of participants who took the opportunity to discuss their 
experiences at one of the open microphones. The contingent from 
Francophone Africa was provided with simultaneous translation 
at all plenary sessions, and several workshops were held in French. 

Speakers at the opening ceremony included Hon. Mwai Kibaki, 
Kenyan Minister of Health, who delivered the Inaugural Address, 
and Dr. Bjorn Thylefors, Manager of the WHO Prevention of Blind- 
ness Program, who delivered the Keynote Address. 

During this five-day meeting, the following subjects were dis- 
cussed at the plenary sessions: national programs in Africa, regional 
progress reports, sustainable manpower development for blindness 
prevention, new developments in the control of major causes of 
blindness, and sustainable national program development. The 
workshop topics included: manpower development, delivery of 
specific eye-care services, major challenges and priorities for the 
delivery of eye-care services, and essential characteristics of a model 
self-sustaining prevention of blindness program, including partners 
such as private industry, NGOs, and WHO. In addition, seven IAPB 
Awards for Lifelong Service to the Prevention of Blindness were 
presented. 

At the Business Meeting on the last day of the Assembly, Mr. 
Alan W. Johns, Executive Director of Sight Savers, was elected the 
new IAPB President and Dr. R. Pararajasegaram became the 
Agency’s new Senior Vice President and President-Elect. 


xv 


xvi Preface 


Major support for this General Assembly included grants from: 
Alcon Foundation; Allergan International; Chibret International 
(Ophthalmic Group of Merck Sharp & Dohme); Senju Phar- 
maceutical Co., Ltd.; and Task Force “Sight and Life” (supported 
by F. Hoffmann-La Roche and Co.). We are very grateful to them 
for their sponsorship of this Assembly. 

This book of proceedings presents the most salient materials 
presented at the Fourth General Assembly. 

— Carl Kupfer, M.D. 

Immediate Past President, IAPB 
Bethesda, Maryland 


President’s Message 


The International Agency for the Prevention of Blindness (IAPB) 
was founded in 1975 to foster universal cooperation against avoid- 
able blindness. Because the majority of cases of blindness worldwide 
are either curable or could have been avoided, the principal goal 
of the IAPB has been to control the four major diseases that cause 
more than two thirds of the blindness in the developing world: 
cataract, trachoma, xerophthalmia, and onchocerciasis. For the past 
15 years throughout the world, this consortium of non-governmental 
organizations, national committees, and the World Health Organiza- 
tion has helped increase public awareness, utilize resources, and sup- 
port sight-conservation programs through the implementation of 
the World Health Organization’s health-care strategies. 

The theme of this Fourth IAPB General Assembly is “Sustain- 
able Strategies —Agenda for the 1990s.” I therefore urge you as a 
participant in this Assembly here in Nairobi to help us develop new 
and better ways to increase and sustain the mobilization of resources 
necessary to terminate needless blindness worldwide. During this 
week, it is crucial for us to harness the expertise of the 400 oph- 
thalmologists, eye-care providers, public health specialists, and 
managers engaged in the fight against avoidable blindness. We must 
listen to the first-hand experiences of the representatives from 
ministries of health, national committees for the prevention of 
blindness, the World Health Organization, and the major non- 
governmental organizations. 

Because this Fourth General Assembly presents each of us with 
the opportunity to reexamine our successes, identify the obstacles 
that have to be overcome, and establish new goals, please com- 
municate the lessons you have learned from your own prevention 
of blindness programs and, by sharing them, intensify the perse- 
verance of all of us to continue in the battle against avoidable 
blindness. 

— Carl Kupfer, M.D. 


XVII 



Welcome Message 


On behalf of the people of the Republic of Kenya, the Ministry of 
Health, and on my own behalf, I hereby extend a warm welcome 
to all the participants of the Fourth General Assembly of the In- 
ternational Agency for the Prevention of Blindness in Nairobi from 
11-16 November 1990. I wish you all a pleasant stay in Kenya and 
happy memories of the conference in Nairobi. 

— Dr A.K. Gikonyo 

Chairman, Prevention of Blindness Committee 
Senior Deputy Director of Medical Services 
Ministry of Health, Nairobi, Kenya 


xix 





















PART 


1 


Opening 

Ceremony 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 



1 


Opening Remarks 

Dr. Carl Kupfer 

Director ; National Eye Institute 

President , International Agency for the Prevention of Blindness 

On behalf of the Executive Board of the International Agency for 
the Prevention of Blindness, it gives me great pleasure to welcome 
all of you participants from more than 60 countries, and particularly 
the national delegates, to this IAPB Fourth General Assembly here 
in Nairobi. This Assembly brings together representatives of the 
World Health Organization, international non-governmental organi- 
zations in official relationship with the IAPB, and 60 national 
committees to discuss the progress we have made in prevention of 
blindness activities during the past four years since the Third General 
Assembly in New Delhi. 

The theme of this Fourth General Assembly is “Sustainable 
Strategies —Agenda for the 1990s.” During this week we will discuss 
not only our achievements but also the obstacles that still remain 
to be overcome. The success of this Assembly will depend on your 
active participation in sharing your own personal experiences with 
the other participants from all over the world. 

I would like to thank the following for providing support for 
this General Assembly: Alcon Foundation; Allergan International; 
Chibret International (Ophthalmic Group of Merck Sharp & 
Dohme); Senju Pharmaceutical Co., Ltd.; and Task Force “Sight 
and Life” (supported by F. Hoffmann-La Roche and Co.). Without 
their sponsorship this Assembly would have been impossible. 

I also want to call special attention to the magnificent job that 
the Coordinating Committee here in Nairobi has done in making 
all of the arrangements that have ensured the success of this 
Assembly. Their efforts include the logistics for transportation, 
registration, and catering as well as the preparation of the venue 
including the translation services, meeting facilities, and the thou- 
sands of details that must be considered to ensure a successful Gen- 
eral Assembly. They are: Prof. Henry S. Adala, Dr. A.K. Gikonyo, 


3 


4 Opening Ceremony 


Ms. Ute Lorenzen, Mr. David Paswa, Dr. Ashok K. Shah, Mr. Paul 
Streets, and Dr. D.S. Walia. I am particularly pleased to introduce 
the Chairman of the IAPB Fourth General Assembly Coordinating 
Committee, Mr. Samuel K. Tororei, the Chief Executive Officer of 
the Kenya Society for the Blind. 


2 


Welcome Address 

Mr. Samuel K. Tororei 

Chairman , Coordinating Committee , IAPB Fourth 
General Assembly 

Chief Executive Officer ; the Kenya Society for the Blind 

Our distinguished guest, Honorable Mwai Kibaki, Minister of 
Health, Republic of Kenya; The President of the International 
Agency for the Prevention of Blindness, Dr. Carl Kupfer; Honorable 
Representatives from the Government of the Republic of Kenya and 
other Governments represented here today; distinguished WHO and 
other UN representatives; distinguished guests; observers; ladies and 
gentlemen: 

I have the greatest pleasure to stand before all of you this morn- 
ing to perform a humble but pleasant duty, perhaps the most 
pleasant of all duties required of me by the conference, to welcome 
you to this opening session of the Fourth General Assembly. 

For us in Kenya, particularly for the members of the Coor- 
dinating Committee and Kenya’s National Prevention of Blindness 
Committee, this opening ceremony marks an important landmark 
in our efforts. We can almost give a sign of relief and say, “Ah, 
you have all come to Nairobi at last and given meaning to our 
planning and anxieties!” I say almost because we shall not do that 
until the conference is successfully completed, and all delegates are 
satisfied. But nonetheless, I think the members of the Coordinating 
Committee deserve a big thank you for enabling us to meet in this 
venue today. 

On their behalf, therefore, I wish to extend a warm welcome 
to all of you who have come from outside of Kenya and even to 
those of you who have come from outside of Nairobi. If I were the 
Mayor of Nairobi, I would say, “I give you the keys to the city.” 
I can assure you that in Kenya much hospitality is available for the 
taking, if only you are able to make yourselves at home and in- 
teract with the beauty that is around you. 

I also wish to note that this conference has set itself a practical 


5 


6 Opening Ceremony 

task: to discuss the importance of establishing sustainable programs 
to solve the problem of blindness globally. It is important that this 
Assembly is taking place for the first time in Africa. Recently, two 
colleagues of mine posed two pertinent questions with respect to 
the overall problem of blindness in Africa, which I will now 
paraphrase for you in the context of this conference. If the prevalence 
of blindness and visual impairment is as great as it is in the world 
today, what will happen by the year 2000 and beyond? Is the health 
for all concept achievable in respect to blindness and vision loss 
by the year 2000 given the present state of eye services? 

I repeat these questions to illustrate that we have come here with 
a serious challenge. It is my hope that, as we make ourselves com- 
fortable and feel at home as I have urged you to do, we shall always 
keep this challenge in the back of our minds. 

Once again, welcome to all of you. I hope our arrangements 
are found to be adequate for your needs. But, if there are any short- 
comings, please let us know and we shall do our best to help you. 


3 


Remarks 

Dr. Akira Nakajima 

President , International Council of Ophthalmology, 
the executive body of the International Federation 
of Ophthalmological Societies 

The Kenyan Minister of Health, the Honorable Mwai Kibaki; Dr. 
Carl Kupfer, the President of IAPB; distinguished guests; ladies and 
gentlemen: 

It is my great honor and pleasure to say a few words on behalf 
of the ophthalmologists in the world at this festive occasion of the 
opening ceremony of the IAPB Fourth General Assembly. 

First of all, we would like to express our hearty congratulations 
to the IAPB for their brilliant achievements in the prevention of 
blindness in the world over the past decade. We would also like to 
congratulate the Coordinating Committee for organizing such a 
wonderful meeting. The International Association for the Preven- 
tion of Blindness was founded in 1929 as an organization under 
the International Federation of Ophthalmological Societies. The 
Association worked jointly with blindness welfare societies in pro- 
moting scientific knowledge about the prevention of blindness in 
the world. However, in 1975 the Association was reorganized into 
the International Agency for the Prevention of Blindness or IAPB. 

Sir John Wilson, our honorary president for life, and Dr. A. 
Edward Maumenee, the former president of the International Coun- 
cil of Ophthalmology, and many other people were instrumental 
in the formation. The activities of the IAPB are jointly supported 
by the International Federation of Ophthalmological Societies 
(IFOS), the World Blind Union, and national societies for the 
prevention of blindness, as well as many non-governmental organiza- 
tions (NGOs) active in the field of prevention of blindness. 

The WHO set out to prevent blindness in 1970 and has included 
this cause in its regular program since 1979. Through the joint ef- 
forts of IAPB, WHO, national ophthalmological societies, national 
societies for prevention of blindness, and NGOs, prevention of 


7 


8 Opening Ceremony 

blindness programs are now active in a majority of countries 
throughout the world. In many countries, these prevention of blind- 
ness programs are often closely related to eye-care services at various 
levels. 

The progress of eye-care science and the training of manpower 
necessary for appropriate eye-care services are often the responsibil- 
ity of national ophthalmological societies. Also, because good visual 
function is directly related to the quality of life of any group of 
people, at its international congresses IFOS has organized sym- 
posiums on the prevention of blindness and on the education of 
ophthalmologists. 

I sincerely hope that the prevention of blindness activities in 
the world, coordinated by the IAPB, will continue to protect the 
eyesight of an increasing and aging world population. The IFOS 
and the IAPB will continue to work together to alleviate this prob- 
lem. Our task ahead is formidable. I wish you all the best for the 
success of the IAPB, and of the meeting. 


4 


Remarks 

Mr. Alan W. Johns 

Vice-President, International Agency for the Prevention of Blindness 
Chairman, NGO Coordinating Committee 

An international conference of this nature could have been held 
in any one of a dozen or more capital cities in the developing world. 
It is therefore all the more significant that, when the Consultative 
Group of Non-Governmental Organizations to the WHO Program 
for the Prevention of Blindness met here in March 1988, they were 
unanimous in wanting the Fourth General Assembly to be held in 
Africa and, if at all possible, in Nairobi. 

A number of factors are involved in choosing a conference venue. 
The most important is ensuring that the host country welcomes the 
prospect. That was assuredly so in Kenya’s case and was anticipated 
by the NGO representatives. They wanted to bring I APB delegates 
from many countries to East Africa and to Kenya, where by far 
the largest number of IAPB’s international NGO members gained 
their knowledge of the strategies appropriate to conditions in Africa. 

This is the region in Africa, particularly Kenya and Tanzania 
with their communities scattered over the vastness of the rural areas, 
where the task of bringing ophthalmic resources to where they are 
most needed was first addressed by the efforts of pioneer ophthal- 
mologists such as Dr. Geoffrey Bisley and Dr. Joseph Taylor. They, 
I am pleased to tell you, are with us in this Assembly today. Among 
many initiatives, they were the first to train ophthalmic assistants 
for a mobile clinic role — that cadre of ophthalmic personnel which 
has since benefitted the lives of many millions of Africans and 
greatly strengthened the objectives of the all-too-few ophthalmol- 
ogists who practice in Black Africa. 

When I think back on my introduction to prevention of blind- 
ness activities in Africa, I am reminded instantly of my first visit 
to Kenya in 1979 and meeting the International Eye Foundation’s 
team on the slopes of Mount Kenya as they put together one more 
part of the Kenya Government’s Rural Blindness Survey— another 


9 


10 Opening Ceremony 


milestone in the understanding of causes and intervention levels that 
was to lead, in Kenya’s case, to the establishment of the National 
Prevention of Blindness Committee that so effectively guides the 
national program today. 

Africa, then, for many international NGOs, attracts attention 
and a fair proportion of resources by virtue of its needs. As one 
of the NGO representatives who met in 1988, I am delighted that 
it has proved possible to hold this Assembly here and am confi- 
dent that its African delegates will bring a powerful urgency to all 
of our discussions. I say that without in the least wishing to overlook 
the fact that this is an Assembly of an international agency with 
a global agenda to consider. You can find the Consultative Group 
of NGOs working in many parts of the world. What they do in 
Africa is a part of that global movement, acting with and through 
national partners of which the IAPB has always seen itself as the 
catalyst. 

Each of these Assemblies to date has provided an opportunity 
for the Agency to examine its role and probe its capabilities. This 
one, with its theme of “Sustainable Strategies— Agenda for the 
1990s,” can be no exception. I sense we have a lean period ahead 
of us, with the multiplication of needs in the developing countries 
and the newly recognized needs of Eastern Europe set against the 
backcloth of a world economy contending with so many priority 
issues. 

With these circumstances in mind, we need here to formulate 
an agenda for the Agency consonant with our theme: a prioritiz- 
ing of our objectives, a radical enhancement of the association be- 
tween all categories of our membership, and a strengthening of the 
ties between the Agency and its regional and national committees. 
This will be a mammoth task, as it has been throughout the Agency’s 
history, but the communities we serve will expect no less of us. 


5 


Inaugural Address 

Hon. Mwai Kibaki 

Minister of Health , Republic of Kenya 

It is my great pleasure to speak at this General Assembly this mor- 
ning, particularly because the persons gathered here not only come 
from many countries with diverse needs and programs, but because 
you represent the main organizations and the top eye surgeons and 
eye-care workers involved in policy formulation and implementa- 
tion in your countries. 

I am informed that this is the fourth time the International 
Agency for the Prevention of Blindness has met since it was founded 
in 1975. I am pleased to note that Kenya has been privileged to 
become the first African country to host this assembly, and now 
joins the United Kingdom, the United States, and India in the honor 
of entertaining the IAPB. Kenya believes very strongly in the value 
of international friendship and human endeavor based on the prin- 
ciples of peace and goodwill to all mankind. I am happy that as 
the festive season which embodies the message of goodwill and love 
among all people draws near, we are gathered in this conference 
center to consider just such and to act: bringing all our faculties 
and all the resources at our individual and collective disposal to 
bear on the prevention and cure of blindness, not just in our in- 
dividual countries, but in the world at large. To me, this is a comfort- 
ing thought. Comforting because all we hear nowadays is infor- 
mation about conflicts among people who have no reason to hurt 
one another. Here we are gathered to deliberate on the possibilities 
of removing or limiting the effects of one human misery, blindness. 

At this point, I think I should share with you a quotation about 
the importance of health to humanity and illustrate the importance 
of our efforts at this Assembly. It reads: “Good health is one of 
the most important contributors to individual welfare. It is an essen- 
tial prerequisite to the enjoyment of almost any other aspect of life. 
And, poor health, which leads to death, will make all other sources 
of satisfaction irrelevant.” 


11 


12 Opening Ceremony 


Even though most causes of blindness do not lead to death, 
blindness does cause enormous social and economic suffering to 
some 35 million citizens of our present world. And yet it seems we 
have the technological possibilities to overcome it. Where have we 
gone wrong? What is it that we should be doing or should have 
done and have not? No doubt these and other questions will form 
the core of your discussions for the rest of this week. I am informed 
that you have set for yourselves the task of exploring the possibilities 
of developing sustainable programs aimed at eliminating preventable 
and curable blindness. I think this is the way to progress. The key 
is the word “sustainable.” Perhaps it is in our planning that we have 
gone wrong, when we failed in the past to consider the sustainability 
of our programs. Now is the time to go back and see if we can put 
things right. We must look at our varied programs and learn what 
we can from them. 

In a small way, we in Kenya hope to contribute to this process 
of self examination by laying before you our own ophthalmic pro- 
gram for scrutiny. I would like to say a few words about it before 
you have a chance to experience it first hand. We estimate that Kenya 
has nearly 250,000 blind persons, over 70 percent of whom need 
not be blind. The primary causes of blindness in Kenya have been 
identified to include cataract, trachoma, and glaucoma. Those of 
us gathered here know that it is possible to cure cataract through 
simple surgery, and that trachoma, xerophthalmia, trauma, and eye 
infections can be prevented. 

Kenya has therefore set its priorities to deal with these specific 
situations. The Kenya Ophthalmic Program has been in existence 
since the 1950s and has steadily expanded both in the coverage of 
geographical areas and in the scope of services it provides. From 
the outset, our government accepted and welcomed non- 
governmental organizations to assist it in providing eye care. This 
arrangement has enabled us to develop the program we have today. 
We as a Ministry are most grateful to our NGO friends for their 
contribution. I believe that this cooperation, which we have built 
over the years, will continue and grow stronger. 

Let me highlight a few achievements we have recorded in our 
ophthalmic program. Kenya pioneered the use of ophthalmic clinical 
officers in cataract surgery. We now have 20 of these officers per- 
forming cataract surgery in district and provincial government 
hospitals under the supervision of our eye surgeons. In addition, 
we now have a staff of 100 Ophthalmic Clinical Officers, forming 
5 percent of the entire Clinical Officer population in 1989-90, as 


Inaugural Address 13 


compared to only one individual in 1960. Both these groups of of- 
ficers must be adequately supervised by ophthalmologists. Our 
ophthalmic training program at the University of Nairobi has pro- 
duced some 25 ophthalmologists since it was started in 1979. Ten 
of these doctors were non-Kenyans and are now serving in many 
parts of Africa and beyond. We now record that all our provinces 
and two major districts are covered by ophthalmologists. Addition- 
ally we still have enough of a surplus to teach at the University and 
at the Kenyatta National Hospital. I think we have a good reason 
to share our joy with all of you. 

Along with the tremendous manpower development just noted, 
there has been steady growth in the scope of the program. In the 
1950s, our program consisted primarily of a curative unit at the 
Kenyatta National Hospital. Since 1960, when the first outreach 
program was started with assistance from the Kenya Society for the 
Blind and the Royal Commonwealth Society for the Blind in the 
form of a mobile eye unit, our outreach program has grown to nine- 
teen mobile eye units serving over 30 districts in the Republic of 
Kenya, an additional mobile teaching unit employed in primary eye 
health education, and an air service taking doctors to the more in- 
accessible parts of this Republic and neighboring countries. 

This growth of outreach programs was matched by a constant 
growth of static eye clinics. Currently there are 46 such clinics 
throughout the republic. This means that more than half of the 
district hospitals have an eye clinic manned at least by an Ophthalmic 
Clinical Officer. The Ministry, through the coordination of the Na- 
tional Prevention of Blindness Committee, has accepted a program 
aimed at upgrading eye clinics throughout the country. The pro- 
gram has started by upgrading the provincial and major district 
hospitals. So far, some 120 eye beds and five eye wards have been 
added over the last five years through assistance from Sight Savers 
(Royal Commonwealth Society for the Blind) of the United King- 
dom, Operation Eyesight Universal of Calgary, Canada, and the 
Kenya Society for the Blind. 

I am pleased to note that the program is poised to grow even 
faster in the future. Staff and hospitals require additional surgical 
equipment and drugs. We are addressing this issue squarely. The 
first National Eye Drops Production Unit has just opened with 
the assistance of Operation Eyesight Universal and Christoffel- 
Blindenmission of Germany. In time this unit will be expected to 
produce the 12 basic eye drops necessary to treat the major eye 


14 Opening Ceremony 


conditions in the country. Supplements will be needed, but this will 
give the program great flexibility and ability to provide services. 
The National Prevention of Blindness Committee is also engaged 
in constantly reviewing the state of the surgical and diagnostic equip- 
ment in all the eye clinics and replenishing their supply whenever 
necessary. 

The few achievements I have highlighted above only serve to il- 
lustrate our determination to prevent and treat blindness in our 
Republic. Central in this effort is the Ministry’s Prevention of Blind- 
ness Committee, charged with the responsibility of overseeing the 
whole ophthalmic program. This committee is doing a good job, 
and the Ministry is committed to its further strengthening to enable 
it to perform even better. For this reason, the Ministry appointed 
an eye surgeon specifically to serve as the program’s coordinator 
and to strengthen the link between the Ministry and the collaborating 
NGOs. Additional staff have and will continue to be assigned to 
the Committee’s Secretariat as the need arises. 

I am therefore optimistic about the future of our ophthalmic 
program. I see a future of greater effort which will yield better 
results. Last year, the Kenya Ophthalmic Program examined and 
treated well over 500,000 Kenyans suffering from eye disease. I am 
sure this number will continue to increase in the future. In 1984, 
eye diseases represented 3.02 percent of all reported diseases. In 1986 
this had dropped to 2.66 percent. Likewise, cataract represented 0.12 
percent of all reported diseases in 1984. However, it dropped to 0.11 
percent in 1986. 

Finally, it is known that cataract is responsible for approximately 
50 percent of blindness in developing countries. In Kenya however, 
recent surveys have established that cataract causes only 30 percent 
of the visual loss in this country. 

Let me once again welcome you to Kenya. Feel at home, and 
please do not go home without visiting our game resources or tasting 
our cultural heritage in other ways. Also, I wish you all fruitful 
discussions in this Assembly as well as a happy stay in Kenya. 

Thank you. 


6 


Vote of Thanks and Affirmation 

Dr. Moses C. Chirambo 
I APB Vice President —Africa 

Our Chief Guest, the Honorable Mwai Kibaki, Minister of Health 
in the Government of the Republic of Kenya; Dr. Carl Kupfer, Presi- 
dent of the International Agency for the Prevention of Blindness; 
Samuel K. Tororei, Chairman of the Coordinating Committee of 
this Assembly; senior representatives from the Government of Kenya; 
representatives of other participating governments, United Nations 
agencies, and of international and national non-governmental 
organizations; delegates; ladies and gentlemen: 

My duty is a pleasant one because it involves the thanking of 
all of you who are here this morning. But it is a challenging task 
because I might fail to mention some very important contributors 
to the success of this Assembly. Should this happen, please accept 
my apology, and understand that I have thanked you even if I have 
not mentioned you by name. 

I am sure all my colleagues join me in thanking the Honorable 
Mwai Kibaki and his officers for finding time in their busy schedule 
to come and participate in our opening ceremony this morning. 

I want to thank Honorable Kibaki for personally making the 
statements we have all heard. The International Agency for the 
Prevention of Blindness can be assured that the Kenya Ophthalmic 
Program is in good hands under the guidance of Kenya’s Ministry 
of Health. 

Surely we all appreciate the efforts of the IAPB President, Dr. 
Kupfer, who has guided the Agency for the past eight years. I thank 
him and his staff at the National Eye Institute for all they have done, 
and especially for persuading the Executive Board to choose Kenya 
as the venue for this Assembly. This is an honor for the whole 
of Africa, and a demonstration of IAPB’s commitment to the 
whole world. 

You will of course remember that the First Assembly was held 
in Europe, the Second in America, the Third in Asia and now the 


15 


16 Opening Ceremony 

Fourth is in Africa. This Assembly could not have taken place 
without the participation of several governments, United Nations 
agencies, and international as well as national NGOs. I thank you 
all for your commitment to and understanding of the ideals of the 
IAPB. 

Last, but not least, I must thank our hosts — the Kenya Preven- 
tion of Blindness Committee and this Assembly’s Coordinating 
Committee. Without their hard work and commitment, I cannot 
see how we could be seated in this beautiful conference center as 
we are now. 

In addition, our thanks go to the management of the Kenyatta 
International Conference Center, the various airlines that brought 
us here, the hotels that are providing us wonderful hospitality, and 
tour organizers that have or will facilitate visits to see the beauty 
of Kenya. 

I think we should all give ourselves a round of applause. 

Thank you. 


7 


Keynote Address 

Dr. Bjorn Thylefors 

Program Director ; Program for the Prevention of Blindness , WHO 

The theme of this, the Fourth General Assembly of the Interna- 
tional Agency for the Prevention of Blindness (IAPB) is “Sustainable 
Strategies— Agenda for the 1990s.” This reflects the achievements 
over the last 15 years in the field of blindness prevention, which 
were also apparent during the Third General Assembly convened 
in 1986 in New Delhi under the motto “A Decade of Progress.” 

It may be useful to all of us to briefly review this situation, and 
try to critically analyze what we have achieved, and where constraints 
remain. This in turn may help us to more easily come to grips with 
what we expect will be sustainable developments in the 1990s. 

First of all, one major achievement today is the worldwide 
awareness of blindness as a major disability problem, causing far- 
reaching social and economic consequences apart from the aspects 
of human suffering and quality of life. The strong rationale for 
preventing blindness is being recognized all over the world, but we 
still seem to have difficulty in translating awareness into action in 
a number of countries. 

Undoubtedly, this is partly due to the present harsh financial 
climate in most developing countries, where an increasing number 
of priorities compete for shares of a decreasing health-care budget. 
This very difficult priority setting between endemic “killing diseases” 
and those that “only” result in morbidity and disability is today 
the tough reality in many ministries of health, particularly in the 
least developed countries. 

The second echelon of achievements should include the develop- 
ment of the primary eye-care concept within primary health-care 
systems as the strategy for all countries within the context of WHO’s 
“health for all by the year 2000.” Much progress has been made 
in this field, with both positive and negative experiences. Never- 
theless, today primary eye care is a universally accepted approach 
with manifold practical projects behind it. Undoubtedly, the further 


17 


18 Opening Ceremony 

development of primary eye care as part of countries’ health-care 
systems will be one of the main preoccupations for sustainable pro- 
grams in the 1990s. 

A third major achievement over the past decade of blindness 
prevention has been the establishment of national prevention of 
blindness programs — today in 66 countries. These national programs 
and committees constitute proof that our approach of bringing 
together ministries of health, WHO, and international non- 
governmental organizations has been right and worthwhile. This 
is another matter which must be given all our attention when con- 
sidering strategies for sustainable programs in the 1990s. It is no 
secret that many of these national programs are still in critical need 
of external support, which so far has been granted by the member 
organizations of IAPB and by others. 

Finally, to keep this list short, the fourth area of significant 
progress is in the development of collaboration between the non- 
governmental organizations and WHO in the field of blindness 
prevention. Much of this achievement has been accomplished by 
the IAPB, in bringing the interested organizations together and in 
playing a supportive role to the WHO Program. Fortunately, the 
role of non-governmental organizations as partners in health 
development is now much more accepted by the United Nations 
(UN) technical agencies. Furthermore, the role of non-governmental 
organizations is of growing importance; their very positive contribu- 
tion is even more apparent now because of the increasing resources 
being made available. 

Having looked briefly at the achievements that have been made, 
we must turn to the more somber picture of the chief remaining 
constraints in the struggle for action in the blindness prevention 
field. Again, the list will be short, to focus only on major issues. 

The main obstacle to action in many countries is still the absence 
of political will. This should not be seen necessarily as indifference 
among national authorities, but rather as a reflection that the case 
of blindness prevention has not yet been presented clearly enough, 
there being perhaps a lack of reliable data on visual disability and 
its consequences, or perhaps a rational and cost-effective program 
of intervention has not been identified. There are of course many 
other possible reasons for the lack of commitment of a government 
to the prevention of blindness, but we should all ask ourselves where 
the main problem lies in such circumstances. If there is a difficulty 
of program structure or resource mobilization, it may be dealt with 


Keynote Address 19 


relatively easily, as a technical matter, but the political climate will 
still determine how much progress will be made. 

A second obstacle, in some countries, is the ambivalence of eye- 
care professionals. This implies the will and commitment of 
ophthalmologists and health administrators to change their work- 
ing habits and to shift from individual, clinic-oriented eye care to 
the needs of the community, particularly in neglected rural areas. 
Other professional concepts include team work, delegation of tasks, 
supervision of personnel, and management of health programs. 
However, these matters are not easily dealt with, and most of us 
working in this field are ophthalmologists with clinical rather than 
managerial backgrounds. Nevertheless, it is obvious that the ophthal- 
mologist is expected to take the lead in blindness prevention pro- 
grams in many countries, and he or she needs to be better prepared 
to undertake all of the tasks implied. 

The ophthalmologist may also have to be prepared to give up 
some of the professional satisfaction of using sophisticated tech- 
nology in individual care, rather than cost-effectiveness in public 
health programs. This point will be highlighted again later in this 
presentation. 

Last but not least, in this short list of constraints to blindness 
prevention, is the topic of resources, in particular those problems 
related to manpower and to money. It is significant that this General 
Assembly takes place in Africa, where we know there is only 1 oph- 
thalmologist available for every 1.2 million people. To make it worse, 
we cannot only consider numbers here, but also the maldistribu- 
tion of qualified personnel, with most specialist services available 
only in major urban agglomerations. 

Whatever solutions we can propose to solve the problems of 
manpower scarcity and maldistribution will help to make progress 
towards establishing sustainable national blindness prevention pro- 
grams. With regard to money, the lack of a reasonable budget for 
a national program or field work hampers activities in many coun- 
tries, but again it usually reflects the harsh economic climate that 
most of the least developed countries will have to live with for the 
next decade, at least. The 1980s has been a “lost” decade in terms 
of the economics in those countries, and we can only hope that 
the 1990s will be more positive. 

The major international non-governmental organizations 
represented here spend well beyond $30 million per year in support 
of blindness prevention, and this may well increase in coming years. 


20 Opening Ceremony 

However, even a larger amount will probably still be insufficient, 
and caution will have to be exercised in the use of such external 
resources, whether they come from non-governmental organizations, 
WHO, or other sources, so as not to create a dependency within 
these countries and national programs on intervention schemes or 
technology that they cannot afford, and therefore sustain, in the 
long run. 

I would like to turn now to what the role of WHO, with its Pro- 
gram for the Prevention of Blindness can be, including working with 
non-governmental organizations, particularly those represented here 
today, that work at the international level: 

The WHO Program will certainly continue to stimulate Member 
States to do more about blindness prevention, supporting its ad- 
vocacy with technical advisory services through visits to interested 
countries by consultants or staff. Available information on blind- 
ness and documentation on strategies for specific disease control 
and national program development will be made available to any 
national coordinator or appropriate group. 

Of particular interest in this context is the simplified 
methodology for population-based assessment of blindness and its 
causes, now tested in a number of countries with very satisfactory 
results. The same, or similar methodology may be adapted for 
monitoring or evaluating results in national programs — which is 
another domain where WHO may be able to help countries, depend- 
ing on the budget available. The issue of evaluation of program 
interventions and results is becoming increasingly important and 
it is today often a sine qua non for funding from many agencies. 
Moreover, the 1990s should be the decade when many national blind- 
ness prevention programs start showing really demonstrable results 
in terms of disease control and disability reduction. 

The development of suitable strategies for blindness prevention 
schemes in countries will be continuously considered through WHO 
support to meetings at the national, regional, and global or inter- 
regional levels. The collective wisdom and experience gained in a 
number of countries will certainly be of great value to others — this 
is part of the working principles and procedures of WHO. The 
Prevention of Blindness Program has developed, over the years, 
rather extensive documentation with guidelines for various blind- 
ness prevention activities, and this will be continuously considered 
in the future. However, as with all cookbooks or recipes, they are 


Keynote Address 21 


useful only when all of the ingredients are there. Unfortunately, this 
is still not the case in all developing countries. 

To overcome part of this constraint, efforts will continue to 
mobilize additional resources to the WHO Program, in support of 
selected national programs. Other measures of support may include 
the convening of national seminars or workshops, fellowships or 
grants for postgraduate studies, particularly in relation to public 
health ophthalmology, and the purchase of ophthalmic supplies and 
equipment in certain countries. However, it has to be stated now 
that the extent to which the WHO Program will be able to support 
all these activities will depend on how much extrabudgetary support 
can be mobilized, and on how much the Program will be in de- 
mand by Member States and included in their WHO budget for 
technical cooperation. As a rule, over the last decade, a majority 
of the funds in the WHO Program has been of extrabudgetary 
origin, and we hope this favorable trend will continue through 
the 1990s. 

In discussing the role of non-governmental organizations 
(NGOs), the first point is that of advocacy. The NGOs can work 
freely in this context to stimulate general awareness and public 
education and to mobilize community support through various 
mechanisms. Whereas the WHO communication channel is usually 
strictly through the Ministry of Health, the non-governmental or- 
ganizations can work in a broader context, and the two spheres 
should complement each other very easily. 

Secondly, work at the “grassroots” level in health projects gives 
the non-governmental organizations a lot of very valuable field ex- 
perience and close community contact. This may be very useful in 
developing and testing alternative approaches to eye-care services 
or disease control, and can be usefully linked to WHO or govern- 
mental schemes on a research or service basis. 

The development and strengthening of manpower is another area 
of great concern to all interested parties, where the non-governmental 
organizations have often taken the lead in new approaches to training 
and development of curricula, particularly for auxiliary health per- 
sonnel. The training of ophthalmic assistants, or clinical officers, 
in most of the African countries today, is an example of such ac- 
tion by NGOs, which is now being taken up and supported by WHO 
and ministries of health. Looking around the world, much of this 
training of personnel in eye care is, however, still being supported 


22 Opening Ceremony 


mainly by the international NGOs. This is particularly true in 
African countries. 

The support provided in many countries to national prevention 
of blindness committees by international NGOs is very important 
in helping national programs to get started. Moreover, this support 
often comes before there are official governmental budgets in order, 
or while waiting for contributions from interested donors. Such a 
mobilization of resources through the NGOs is of critical impor- 
tance in a number of national blindness prevention programs. This 
situation is likely to continue as far as some of the least developed 
countries are concerned, where major new resources are not likely 
to come forward within the foreseeable future. 

Another important role for the NGOs and WHO is the develop- 
ment of training aid in eye care. There has already been a successful 
experience of joint work between the WHO Program and interested 
NGOs, using available experience and possibilities for field testing 
of new material. The printing of such training aids in various 
languages by WHO and the distribution through both NGO and 
WHO channels offer obvious advantages for all involved. Similarly, 
the documentation and dissemination of developments in ap- 
propriate technology for eye care, as in the field of low-cost spec- 
tacles and the local production of eye drops, can profit from the 
joint work of NGOs and the WHO Program. 

Having looked at the possible roles of the WHO Program and 
the collaborating NGOs in support of eye-care and blindness preven- 
tion programs, we may now turn to the issue of requirements and 
strategies for sustainable national programs in the 1990s. It is, of 
course, only possible to highlight some of the key issues, and not 
necessarily in order of priority; each country has its specific set- 
ting in that context. 

The following nine points should be considered in the scenario 
of sustainable programs: 

1. To obtain baseline data on blindness and its causes in coun- 
tries where this is still needed for program planning. This 
refers to those countries where there is a critical absence of 
reliable data and where extrapolations to other settings are 
difficult. The WHO simple population-based survey meth- 
odology could be used in small-scale assessments for rea- 
sonable costs in most of those countries over a short period 
of time. The main constraint here is the lack of funds to cover 


Keynote Address 23 


local costs, including transport. It is likely that, unless the 
lack of data is overcome in those countries concerned, any 
firm governmental commitment cannot be expected, and thus 
any program will be delayed or not started. 

2. To improve communications between national coordinators, 
or blindness prevention advisers or groups, and political 
decision-makers, and to firmly establish and maintain blind- 
ness prevention as a priority issue. This communication 
should maintain visibility and commitment by channeling 
information from ongoing programs to ministries of health 
and the public. 

3. To develop further eye care as part of primary health care, 
wherever needed, and to look carefully at cost implications. 
Such eye-care schemes should also be evaluated from the 
consumer’s point of view to make sure they are seen as 
appropriate. 

4. To increase public awareness and to mobilize more commun- 
ity support for eye-care and blindness prevention schemes, 
ensuring full utilization of available services and thus op- 
timizing the cost-benefit aspect. 

5. To create a manpower development situation that makes full 
use of specialist services, but for specialized care only, with 
proper delegation of other tasks and routine work. This im- 
plies a heavy reliance on trained auxiliary personnel in many 
developing countries in the present and probably a persisting 
scarcity of specialists, particularly in rural areas. 

6. To set up an efficient managerial structure for the national 
program, with promotion of teamwork, and with regular sup- 
port to and supervision of personnel at the primary health- 
care level from those higher. It is important that there is a 
two-way communication channel between the levels of eye 
care. In addition, a meaningful feedback on reporting pro- 
cedures is a must, if they are to succeed. 

7. To include an obligatory component of monitoring and eval- 
uation in all national programs, in order to demonstrate 
success or failure, and to analyze constraints in program pro- 
cedures. The options for evaluation mechanisms, as worked 
out by the WHO Program should be considered and adapted 


24 Opening Ceremony 

to local needs. Obviously cost-effectiveness has to be borne 
in mind when setting up evaluation schemes, but any sus- 
tainable program should reliably document results and 
achievements. 

8. To vigorously pursue the mobilization of resources for na- 
tional programs on the widest possible scale. Attention should 
be given to bilateral aid agreements, where a health project 
component exists that could include eye care. Other poten- 
tial contributors may include community support groups, in- 
dustry, and interested humanitarian or commercial societies 
in some countries. The financing of health services is a field 
where new and innovative approaches are particularly needed, 
and it is likely to become the most critical issue for sustainable 
strategies and programs. 

9. To set up a mechanism for applied research as part of na- 
tional programs, which may be used to generate, test, and 
evaluate technology and procedures for improved program 
interventions. Operations research, looking at the stream- 
lining of a specific process, is of particular interest to ensure 
and to document the optimal utilization of available 
resources. 

It is not possible to specify one single critical factor for sus- 
tainable national blindness prevention programs. However, it is likely 
that the three issues of resources, managerial structure, and evalua- 
tion of results will become the major issues during the coming 
decade. There have been various estimates as to the level of fun- 
ding that would be needed to solve the world blindness problem. 
However, of more importance is the rapidly growing magnitude of 
the problem if the present situation is not tackled immediately. The 
often quoted estimate that the world’s blind population will have 
doubled by the year 2025, if no major action is taken now, still 
stands. However, it can be confidently stated that a lot can be done 
between now and the year 2000. 

If we want to achieve a major impact on the burden of blind- 
ness in developing countries, there is a clear need to unite the forces 
of ministries of health, WHO, and non-governmental organizations, 
and to put all efforts and resources into attacking the public health 
dimension of blindness, which is solvable today, but perhaps will 
not be manageable by the generation of tomorrow. 


PART 2 


PLENARY SESSION I 

National 
Programs 
in Africa 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 
















































































1 


National Program Development: 

East and Central Africa 

Dr Moses C. Chirambo 

In 1984, it was estimated that there were between 27 and 35 million 
persons blind (based on the WHO definition of best-corrected visual 
acuity in the better eye of less than 3/60) from all causes. Of these, 
6 million blind persons live in Sub-Saharan Africa. The main causes 
of blindness and visual impairment are cataract, trachoma, on- 
chocerciasis, glaucoma, trauma, and nutritional blindness due to 
measles and vitamin A deficiency. 

Although there are no exact prevalence rates of blindness in most 
countries of the African Region, inferences made from a few 
population-based surveys suggest that the blindness rate (visual 
acuity in the better eye of less than 3/60) in the region is 1.0 to 1.5 
percent. Almost all the countries of the region have formed national 
committees for the prevention of blindness. However, not all of these 
committees are currently active. 

With the exception of onchocerciasis, it is possible to formulate 
plans for the prevention of blindness on the basis of a 1.0-1. 5 per- 
cent blindness rate without waiting for population-based surveys. 
With this in mind, Tanzania, Zambia, Swaziland, Botswana, 
Lesotho, Uganda, Sierra Leone, and Ghana have formulated na- 
tional plans. 

In Africa there is an acute shortage of skilled manpower. The 
ratio of doctor to patient varies from 1 doctor per 15,000 to 1 doc- 
tor per 50,000, and there is only 1 ophthalmologist for every 
1,000,000 Africans. Coupled with this ratio is the very high popula- 
tion growth of 3.5 to 4.5 percent per year. This means that despite 
intensive medical training programs, the doctor-patient ratio will 
not improve. We must, therefore, lean increasingly on the use of 
non-ophthalmologists to fill the many gaps. This will most certainly 
apply to staffing of clinics at all levels of eye-health care. 

One of the most remarkable features of the development of 


27 


28 Plenary Session I— National Programs in Africa 

international NGOs for the prevention of blindness during the past 
years has been the shift from direct service to manpower develop- 
ment. More and more, direct service on the part of international 
NGOs working in Africa, such as Sight Savers, Christoffel- 
Blindenmission (CBM), the International Eye Foundation (IEF), 
and Helen Keller International (HKI), see direct service as necessary 
components of sound teaching rather than as an end in itself. The 
main thrust during the period under review therefore has been the 
development of training programs for eye-health personnel within 
the eye-care programs. 

In Kenya, Gambia, Ethiopia, Sierra Leone, Zimbabwe, Tanzania, 
and Malawi, training that leads to a designation of ophthalmic assis- 
tant is being offered at the paramedical/nursing training centers. 
The ophthalmic assistant is used to provide eye-care service at the 
primary and secondary levels. 

In a few countries of East, Central, and Southern Africa some 
ophthalmic assistants and general medical officers are being trained 
as cataract surgeons. Kenya, Tanzania, and Malawi train ophthalmic 
assistants as cataract surgeons and Zimbabwe trains general medical 
officers as cataract surgeons. Training leading to a postgraduate 
qualification in ophthalmology is conducted in Mali, Nigeria, Kenya, 
Uganda, Ghana, and Tanzania. However, the output of ophthalmol- 
ogists in these institutions is still inadequate to meet national 
manpower targets. In most of these training programs, the imple- 
mentation is a cooperative effort within the country and includes 
the WHO and non-governmental organizations such as Sight Savers, 
Operation Eyesight Universal, Christoffel-Blindenmission, Helen 
Keller International, and the International Eye Foundation. 

During the last several years, WHO and international NGOs 
in collaboration with ministries of health have organized several 
workshops. During July 28-29, 1987, Malawi hosted a Southern 
African Subregional Ophthalmic Training Center (SADCC) Tech- 
nical Expert Meeting on the training of ophthalmic assistants for 
the region. Besides the review of the training program, participants 
discussed the role of IAPB in the formation of national commit- 
tees for the prevention of blindness. The last several years have wit- 
nessed the formation of more national committees for prevention 
of blindness, the development of national plans, and the establish- 
ment of training programs for the secondary level of eye-health care. 


2 


National Program Development: 
Ethiopia 

Dr Pawlos Quana’a 


THE ETHIOPIAN PREVENTION OF 
BLINDNESS PROGRAM (EPBLP) 

The EPBLP was formally established in 1986 along with The Na- 
tional Committee for the Prevention of Blindness (NCPBL). The 
EPBLP’s broad goal is to reduce the estimated rate of blindness 
in the country from 1.5 percent to 0.5 percent. Its main activities 
so far have been: carrying out limited field surveys, participating 
in school health programs, performing tarsotomies in the field, par- 
ticipating in the field training of ophthalmic medical assistants, and 
distributing educational posters and Vitamin A in collaboration with 
the International Eye Foundation and Helen Keller International. 

Ethiopia is committed to implement primary health care as a 
means of achieving health for all by the year 2000. Good ground 
work has been laid to enable the realization of this goal. Our goal 
of blindness reduction can only be achieved through this means. 
Unfortunately, manmade and natural calamities have been thwart- 
ing all the efforts that Ethiopia has put forth. Our nation is striv- 
ing to catch up with other African countries in program coverage. 


DEMOGRAPHIC CONSIDERATIONS 


1990 estimated population 
Infant mortality 
Life expectancy 
Population growth 
Birth rate 


52,000,000 

139/1000 


48.5 years 
2 . 9 % 
4.6% 


29 


30 Plenary Session I— National Programs in Africa 


HEALTH FACILITIES AND 
MANPOWER CONSIDERATIONS 


Hospitals 

89 

Hospital beds 

11,779 

Clinics 

2292 

Ophthalmic centers 

16 

Health centers 

160 

Ethiopian doctors 

1658 

Health officers 

90 

Nurses 

3575 

Health assistants 

10,045 


Ophthalmologists 24 

Eye resident trainees 15 

Ophthalmic 

medical assistants 59 

Community health 
agents 14,319 

Traditional birth 
attendants 12,219 


By utilizing these health workers, it should be possible to inculcate 
the importance of blindness prevention both in health professionals 
as well as in the general public. 

SUSTAINABLE STRATEGIES 

The EPBLP is attempting to plan feasible programs that will be 
maintained for the duration of the 1990s. To make any of its pro- 
grams successful, trained manpower, financial resources, and sound 
administrative support must exist. 

In the last three years the International Eye Foundation (IEF) 
and Helen Keller International (HKI), in collaboration with the resi- 
dent staff of the Addis Ababa University, have trained 59 ophthalmic 
medical officers and equipped them with basic ophthalmic 
instruments. 

However, the one-year training of these officers is inadequate 
if we are to tackle the existing cataract backlog. Refresher courses 
at their training sites as well as their remote working places must 
be devised; and such an upgrading course is planned for early 1991. 

Ethiopia has become like a marantic child who, with each recur- 
ring infection, has to be resuscitated. Prof. Nakajima aptly stated 
in the August 1989 issue of the I APB News that “World peace and 
economic prosperity form the basis for good health. ...” 

Ethiopia and the EPBLP are optimistic that tomorrow will bring 
about a situation in which sustained strategies in the prevention of 
blindness can be implemented throughout the country. 


3 


National Program Development: 

The Gambia, including Demographic 
and Manpower Considerations 

Dr. Hannah B. Faal 

The Gambia is a small country on the west coast of Africa com- 
prising 10,600 square kilometers and a population of 800,000. 
Unfortunately, The Gambia is one of the least developed countries 
in the world and depends on tourism and the export of peanuts 
for revenue. 

The Gambian government attaches great importance to the de- 
velopment of a sustainable health service. In the pursuit of this goal 
in 1979 The Gambia offered itself as a model for the development 
of a primary health-care system to the West African Health Com- 
munity. The development of the National Eye-Care Program has 
been aided by The Gambia’s small population and geographical size. 

The National Eye-Care Program was started in 1985 with the 
dual objective of reducing blindness prevalence rates and making 
eye care available to the entire population through primary health 
care. It has this general pattern: community-based eye services are 
provided by community personnel; general health facility services 
are provided by general static health facility workers. Ophthalmic 
health is provided by ophthalmic paramedics at a service facility 
at the second level, as well as by staff at a facility at the third level, 
which includes an ophthalmologist. There is movement between the 
different levels: downwards through patient referral chains and up- 
wards through health personnel for training, supervision, support, 
and outreach work. 

This six-year Program has had three phases, with coverage of 
one region for every two-year phase. Three medical regions have 
been covered: West Africa, Central Africa, and East Africa. 


31 


32 Plenary Session I— National Programs in Africa 

ACHIEVEMENTS 

In 1986 a population-based national survey provided the following 
data on blindness. The prevalence rate of blindness was 0.7 percent 
and the major causes of blindness were: cataract (55 percent), 
trachoma/corneal scaring (17 percent), and other corneal scaring/ 
phthisis (20 percent). The survey also provided the geographical 
distribution of blindness by cause in The Gambia. The survey design, 
methodology, results, and recommendations were made available 
to WHO for adaptation by countries and regions in similar 
geographic and economic circumstances. 


MANPOWER DEVELOPMENT 

Although we started with only one ophthalmologist and one 
ophthalmic nurse, so far the following personnel have been trained 
or are currently in training: one ophthalmologist in training, two 
cataract surgeons, four ophthalmic medical assistants, two com- 
munity eye health educators, and two dispensing opticians. 


STRATEGIES ADOPTED 

The following strategies have been adopted because of The Gam- 
bia’s lack of specialist manpower: short, practical training for the 
ophthalmologists; use of paramedics trained from available medical 
personnel; use of cataract surgeons; employing a slow pace of 
training — one ophthalmic medical assistant per year is trained in 
Malawi; multidisciplinary training for specialist ophthalmic staff, 
includes community eye health concerns and teaching skills; and 
the use of a primary eye-care education unit. 


PRIMARY EYE-CARE TRAINING MODULES 

These modules have been developed for the following non-specialist 
cadres: village health workers and traditional birth attendants; school 
eye-health teachers; community health nurses; health center staff; 
leprosy attendants; and students of nursing, public health, and 
teacher-training institutions. 

The Gambia’s primary health-care structure has been well es- 
tablished, making it easier to integrate primary eye care. Nearly the 
entire western region of the nation has been covered. 


The Gambia 33 


SUPPORT SERVICES 

A local eye-drop production unit has been set up; and a low-cost 
spectacles workshop has been established. Also now in place are: 
mobile eye units, which are used primarily for community train- 
ing; facilities for outreach cataract surgery; and satellite clinics in 
peri-urban areas. 


SPECIAL PROGRAMS 
Cataract 

In The Gambia cataract is responsible for 55 percent of blindness 
and has a backlog of 5,500 cases. The following strategies have been 
adopted: a two-table, two-surgeon routine in the operating theater; 
patient recruitment by community health workers; patient screen- 
ing by community eye nurses; outreach village health center cataract 
surgery with patients discharged the first day after the operation 
to homes in the same village and daily wound dressing by a com- 
munity health nurse; and eye examination and dispensing of stan- 
dard + 10.00 spectacles one week after the operation by the 
ophthalmic staff. By employing these strategies and performing 500 
operations per year, we have been able to keep up with the estimated 
incidence. 

Trachoma 

Lid surgery techniques have been taught to all ophthalmic medical 
assistants and community eye nurses; the number of patients re- 
quiring surgery is steadily decreasing. 

In an attempt to control trachoma, all specialist staff are taught 
the risk factors for trachoma, its recognition, treatment, and preven- 
tive measures. The WHO primary health-care management of 
trachoma has been field-tested in The Gambia; and the develop- 
ment of a protocol for its adaptation to The Gambia is in process. 

STATIC FACILITIES 

The original hospital eye unit has been expanded and upgraded for 
service and training. A secondary eye center has been established 
in the central region of the country. 

Monitoring and evaluation indicators have been limited to 


34 Plenary Session I— National Programs in Africa 

enumerating the following: patients seen, surgical procedures per- 
formed, personnel trained, and facilities established. 

In summary, eye care in The Gambia has been integrated into 
the primary health-care structure of the western region of the coun- 
try. Other strategies and modules have also been developed in The 
Gambia for replication in other regions of Africa. 

The Gambia Eye-Care Program cooperates with the Interna- 
tional Centre for Eye Health in London particularly in the areas 
of training and research and with the WHO Prevention of Blind- 
ness Program in field research and workshops. Sight Savers (Royal 
Commonwealth Society for the Blind) has assisted in the develop- 
ment of The Gambia Eye-Care Program as a model for providing 
more ophthalmologists. 


PROBLEMS, FAILURES, AND CONSTRAINTS 

In areas of overlap or dependence on other service areas, there often 
are problems when the recognition of need and the development 
of strategies are performed by eye-care personnel but the task of 
successful implementation is left to personnel other than those in 
the eye-care field such as opticians, pharmacists, and civil servants. 

Often there are problems when a new cadre and career struc- 
ture is developed from established professional bodies. Examples 
include instructing ophthalmic medical assistants, and teaching 
nurses to be cataract surgeons. The low-priority status accorded 
blindness by health planners when compared to life-threatening con- 
ditions is a major concern. Perhaps such issues can be addressed 
in future workshops. 

The Gambia Eye-Care Program aims to: expand into the cen- 
tral and eastern regions of The Gambia, consolidate in all areas, 
and through monitoring and evaluation identify areas of weakness 
and correct them; act as a stimulus and share experiences with other 
countries in West Africa using what has been learned from the East 
African national programs; and, after having achieved a minimum 
eye-care service for the entire country, improve on the sophistica- 
tion of sustainable service at the tertiary center. 


4 


WHO Technical Cooperation in Africa, 
a Situation Analysis 

Dr T. Tukai 

Acting WHO Representative , Nairobi , Kenya , 
on behalf of the Regional Director ; 

WHO Regional Office for Africa 

The Regional Program for Prevention of Blindness started in 1978. 
The subsequent General Program of work acknowledged the social 
and economic impact of blindness and has made its prevention a 
major priority. Whereas the prevalence of blindness in the coun- 
tries of Latin America is 0.2 percent, the rate in the Africa Region 
has been estimated to be 1.2 percent; but in some countries the rate 
is as high as 3.0 percent. Given that the total population of the region 
is about 400 million, it is acknowledged that about 5 million people 
are blind, and more than twice this number are afflicted by severe 
visual impairment. 

This trend has been confirmed by national population-based 
surveys carried out in the Congo and Togo last year. Other limited 
surveys were also carried out in Burundi, Central African Republic, 
Chad, Gabon, and Zaire in Subregion II and Botswana, Lesotho, 
and Mozambique in Subregion III. 

Country reports have also confirmed the general paucity of im- 
portant health personnel resources such as ophthalmic health man- 
power. The ratio of ophthalmologists is 1 per 1 million of popula- 
tion; and until recently there were none in Chad, Central African 
Republic, and Swaziland. 

Most of the ophthalmologists in Africa are expatriates who are 
rendering curative and sight-restorative services in urban centers. 
In some countries, notably those in East and Southern Africa, eye- 
care services are being rendered by ophthalmic medical assistants, 
mainly at provincial and district levels. 

The WHO project for the control of onchocerciasis in West 
Africa has registered satisfactory progress through its vector control 


35 


36 Plenary Session I— National Programs in Africa 

activities. However, the disease still presents a major public health 
problem in the untreated areas. 

Trachoma remains a major problem in most countries of the 
region. Vitamin A deficiency is increasingly being acknowledged 
as a major cause of blindness in drought-affected countries of the 
Sahel as well as East and Southern Africa. The situation regarding 
glaucoma is not clearly known, but the phenomenon is already a 
major public health problem. 

It is acknowledged that the highest rates of blindness in the world 
may be found in some countries of Africa; but this blindness could 
be prevented or cured through good hygiene, adequate food, vec- 
tor control, safety measures, as well as early detection and treat- 
ment of eye diseases. Many countries are becoming aware of these 
and other measures, including the availability of technology for their 
prevention. Inadequacy of trained personnel constitutes a major 
constraint in the endeavor to formulate and implement realistic 
programs. Lack of finance and other resources is another major 
drawback. 

The objectives of the WHO Program are: 

1. To eliminate avoidable blindness. 

2. To promote ocular health and provide essential eye care for 
all. 

3. To reduce the national blindness rate to less than 0.5 per- 
cent, and to ensure that the rate in any given community is 
not more than 1.0 percent. 

WHO Program activities are focused on the following areas: 

1. Encourage formation of a national committee for preven- 
tion of blindness. 

2. Support activities for collection and dissemination of data 
on blindness, including risk-inducing factors. 

3. Formulate and implement national blindness prevention 
programs. 

4. Participate in training programs for all categories of health 
worker, especially ophthalmic medical auxiliaries. 

5. Produce and disseminate basic training aids for district and 
public health workers. 


WHO Technical Cooperation in Africa 37 

6. Mobilize funds and other resources in support of national 
programs for prevention of blindness and for research 
activities. 

Let us take these activities one at a time: 

1. Encourage formation of a national committee for 
prevention of blindness. 

Rapid implementation of action plans can be assured through 
the National Committee for the Prevention of Blindness. This 
coordinatory machinery is chaired by a senior public health ad- 
ministrator at the Ministry of Health. Its composition includes 
representatives from the faculty of medicine, other governmen- 
tal institutions, and non-governmental organizations, including 
the national society for the blind. 

2. Support activities for collection and dissemination of data on 
blindness, including risk-inducing factors. 

In 1981, WHO-supported surveys on blindness were carried out 
in Botswana, Ethiopia, Lesotho, Malawi, Swaziland, Togo, Zam- 
bia, and Zimbabwe. In 1983, a study was carried out in Niger 
on problems caused by blindness in relation to socioeconomic 
development in the country. In 1986, surveys were carried out 
in Burkina Faso and in Ethiopia. In 1986-87, a national survey 
was conducted in Togo, the results of which have been published 
in March 1989 in the weekly WHO epidemiological bulletin, No. 
12, page 87. 

The results of a national survey carried out in the Congo in 
1988 have indicated a national blindness rate of 0.3 percent, which 
is among the lowest in the African Region. On the basis of this 
survey, there was not a single case of blindness attributable to 
onchocerciasis. 

Also in 1988, WHO-supported surveys were also carried out 
in Botswana, Burundi, Central African Republic, Equatorial 
Guinea, Gabon, Lesotho, Mozambique, and Zaire. In 1989, 
surveys were made in Swaziland, Zambia, and Togo. In 1990, 
one survey was carried out in Benin. 

These surveys have stimulated efforts for the prevention of 
blindness to the extent that most countries are now aware of the 
problem and are taking preventive measures to the extent possible. 


38 Plenary Session I— National Programs in Africa 

3. Formulate and implement national blindness 
prevention programs. 

WHO Member States have called for resolute measures towards 
the integration of blindness prevention programs into community 
health services. The African Regional Office is already 
strengthening its efforts towards this direction through a three- 
phase scenario, and the program is accordingly being reoriented. 

To date, only 17 countries of the region have formulated na- 
tional programs for prevention of blindness: Botswana, Burkina 
Faso, Chad, Gambia, Ghana, Kenya, Lesotho, Malawi, Mali, 
Mauritania, Niger, Nigeria, Swaziland, Tanzania, Uganda, Zam- 
bia, and Zimbabwe. These programs are under the management 
of the chief government ophthalmologist or another officer who 
is answerable to the Director of the Division for Disease Preven- 
tion and Control. At the central level his main responsibilities 
include the determination of priorities, mobilization and alloca- 
tion of resources, provision of support at all levels of eye care, 
organization of training and health education programs, and 
monitoring and evaluation of program activities. He also pro- 
motes and coordinates epidemiological studies on blindness. 

4. Participate in training programs for all categories of health 
workers, especially ophthalmic medical auxiliaries. 

This program fosters the training of ophthalmic health person- 
nel and must ensure their retention and equitable geographical 
distribution in the country. The ophthalmic nurse and medical 
assistant is the mainstay of primary eye care. In many African 
countries, they provide services at district and intermediate levels. 
Tertiary eye care is usually provided by qualified ophthal- 
mologists. Only 12 countries have established training institutes 
for ophthalmic manpower. Training for ophthalmologists is cur- 
rently available in Cote d’Ivoire, Kenya, Mali, Nigeria, Senegal, 
Tanzania, and Zaire. Ophthalmic medical assistants are being 
trained in Ethiopia, Kenya, Malawi, Mali, Nigeria, and Tanzania. 
Training of optometrists is available in Nigeria, and Tanzania 
is conducting training of assistant ophthalmic opticians. 

In addition, the regional program for the prevention of blind- 
ness enjoys a very fruitful collaboration with NGOs supporting 
blindness programs. They have jointly organized several seminars 
and workshops as well as training and service-oriented activities. 


WHO Technical Cooperation in Africa 39 

In 1980, subregional workshops were held at Lilongwe, 
Malawi, and Accra, Ghana. In 1983, WHO supported the 
organization of a national symposium held at Ndola, Zambia. 
In 1984, a regional seminar was held at Moshi, Tanzania, followed 
by a subregional seminar in Kampala, Uganda. A task force for 
prevention of blindness was held at Brazzaville, Congo, in Oc- 
tober 1986. During the same year, WHO supported the organiza- 
tion of a national seminar in Mauritania. A subregional seminar 
on prevention of blindness was held at Bujumbura, Burundi, in 
November 1987, followed by a regional workshop on manpower 
development for blindness prevention in Africa held at Accra, 
Ghana, in 1988. A similar seminar took place at Lome, Togo, 
in April 1990. 

The support of WHO to the Lilongwe School of Health 
Science and the WHO Collaborating Center at the Institute of 
Tropical Ophthalmology (IOTA) at Bamako has been instrumen- 
tal in bringing about favorable results attained in the training 
of the ophthalmic health personnel who now serve in several 
countries of the region. 

Fellowships have been offered for training ophthalmic health 
personnel in institutes in Africa and abroad. Recent beneficiaries 
of this program are Chadian and Centrafrican medical doctors 
now undergoing postgraduate training in ophthalmology at 
Bamako, Mali. 

5. Produce and disseminate basic training aids for district and 
public health workers. 

Available technical information and documentation is currently 
being widely distributed. One such document that has attracted 
considerable interest is the poster on “Prevention of Blindness 
through Primary Eye Care.” This poster is available in English, 
French, Portuguese, Swahili, and most recently in Hausa. 

6 . Mobilize funds and other resources in support of national 
programs for prevention of blindness and for research activities. 

This program has been an important tool for the promotion of 
ocular health and for the provision of essential eye-care services 
in these countries. To this effect, WHO Member States are call- 
ing for the provision of resources that are beyond the capacity 
of WHO. The amount of funds allocated for blindness prevention 


40 Plenary Session I— National Programs in Africa 

from country program budgets grew from zero in 1980-81 to 
$131,000 during the 1988-89 biennium. Although modest, this 
indicates the interest of the member states. The main source of 
extrabudgetary funds has been the Japanese Shipbuilding In- 
dustry Fund, which in 1988 provided $107,000 for prevention of 
blindness in the African Region. However, only $60,000 was pro- 
vided last year. 

Regular budget and extrabudgetary funds have been used to 
purchase drugs and equipment in support of community eye care 
in the region’s countries. Recent beneficiaries of these projects 
are Central African Republic, Chad, Ghana, Mozambique, Niger, 
Uganda, and Zambia. The activities in the countries also depend 
to a considerable extent on the support of those non- 
governmental organizations involved in the African Region. The 
importance of the role played by these NGOs is fully recognized 
and appreciated by the Member States and by WHO. 


RECOMMENDATIONS 

The following are among the most salient recommendations: 

1. Program activities should be reoriented and developed in line 
with a three-phase scenario for health development. 

2. The need and importance of community health workers, 
ophthalmic medical assistants, and nurses must be considered 
of the utmost importance in the countries of the region. 

3. There is a need for developing more training centers for 
ophthalmic medical assistants and nurses that are open to 
all the other countries of the region. 

4. Those countries that have not done so should be stimulated 
towards establishing national programs for prevention of 
blindness. 

5. There is a need for assisting and supporting countries to carry 
out more national surveys on the situation and trends of 
blindness. 

6. There is a need for establishing one or two more WHO Col- 
laboration Centers for Prevention of Blindness. It is noted 
that the Institute of Tropical Ophthalmology at Bamako 
(IOTA) is the sole WHO Collaborating Center for Preven- 
tion of Blindness in the African Region. 


5 


National Program Development: 
Resources Mobilization 
and Management 

Dr K. Kagame 

Every country needs an effective national committee for preven- 
tion of blindness to formulate a marketable national program. It 
is a widely believed that a well-written proposal cannot fail to get 
funding. 


PROPOSAL FORMULATION 

A national program is a Ministry of Health document comprising 
many mini-projects that the Ministry uses to solicit funds from the 
government’s treasury and from external sources. A national com- 
mittee for prevention of blindness, using its flexibility to avoid 
unnecessary bureaucracy, is in a better position to market the mini- 
projects to international donors. Most donors now require project 
proposals that include detailed budgeting. Although in most eye- 
care programs, ophthalmologists are often required to produce these 
proposals, most of us are hopelessly ill-prepared for such a task. 
I have witnessed delays and cancellations of proposed projects 
because of shortcomings in ophthalmologists. In Uganda, we have 
been struggling with a document on onchocerciasis for the past four 
years — while the disease continues to take it toll. 

I propose that we eye-care workers aggressively seek help from 
local professionals in the business-planning sector. We can then 
apply for technical assistance from WHO and other international 
agencies to complete our plans. However, I also call upon WHO 
and those international agencies to intensify their efforts in train- 
ing our local eye-care project managers in managerial skills. 


41 


42 Plenary Session I— National Programs in Africa 

SOURCES OF RESOURCES 
Internal Sources 

Where a national eye-care program exists, its budget is likely to be 
incorporated in the national budget. That source is important be- 
cause sustainability of programs depends on it. It is also impor- 
tant because when supplementary funding has to be sought from 
international donors, that local effort is a favorable influence in 
determining whether the donor will fund a project or not. Ministries 
of health require departmental budgets to make their budgetary ap- 
plication to the national treasury. But once the funds are allocated, 
they need these departments to apply for them to implement their 
projects. A well-organized program helps the ministry both to get 
funds and to spend its allocation. 

In Uganda, last year’s Auditor General’s report was critical of 
ministries for not spending their allocations. Perhaps with this as 
a contributory factor, the Ministry of Health’s budgetary alloca- 
tion has shrunk from 10 percent to 4 percent over the last decade. 

On a more positive note, over the last year, we have strengthened 
our national committee for prevention of blindness, and the form- 
ulation of a national program is nearly complete. We hope to help 
the Ministry of Health mobilize resources and utilize them 
appropriately. 


External Sources 

Recourse to international aid is supplementary and temporary. It 
is most important in getting projects through the initial costly phase 
especially when it is necessary to fund capital development. Suc- 
cessful application for funding is helped by: 

1. Having an effective national committee for prevention of 
blindness to negotiate for this aid and give the donor con- 
fidence that programs will be implemented as planned. 

2. Having a well-documented national program that includes 
the project for which funding is being sought. 


PART 



PLENARY SESSION II 

IAPB 

Regional 

Progress 

Reports 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 



1 


Regional Progress Report: 

East, Central, and Southern Africa 

Dr. Moses C. Chirambo 

The countries constituting the East, Central, and Southern African 
Subregion are Angola, Botswana, Ethiopia, Kenya, Lesotho, Malawi, 
Mozambique, Namibia, Swaziland, Tanzania, Uganda, Zambia, and 
Zimbabwe. 

The prevalence of blindness in the subregion, which has a 
population of about 160 million, is estimated at 1.2 percent. There 
are about 2 million blind people and another 2 million who have 
severe visual impairment. 

These prevalence rates have been confirmed by national 
population-based surveys carried out in Kenya, Malawi, Zambia, 
and Ethiopia. The major causes of blindness in the subregion are 
cataract, trachoma, glaucoma, and xerophthalmia. Blindness from 
cataract represents over 50 percent of all blindness cases. 

Blindness can be prevented or cured through proper hygiene, 
proper food, adequate safety measures, and early detection and 
treatment of eye diseases. However, the scarcity of ophthalmologists, 
ophthalmic nurses, and ophthalmic assistants constitutes a major 
constraint on these endeavors. 

In the subregion, the available number of ophthalmologists is 
estimated to range from 1 per 1 million of population in Tanzania 
to 1 per 2 million in Malawi. Only four out of 13 countries, Kenya, 
Tanzania, Ethiopia, and Uganda, have established training institu- 
tions for ophthalmologists. Moreover, the output of ophthalmol- 
ogists from these institutions is inadequate to meet the African 
Regional target of 1 ophthalmologist per 500,000 of population. 
To overcome these constraints, policies have been reviewed to give 
special emphasis to the training of ophthalmic assistants. 

One of the most remarkable features of the international NGOs 
for the blind working in the subregion has been the shift from pro- 
viding only services to providing manpower development assistance 


45 


46 Plenary Session II— I APB Regional Progress Reports 

as well. The main thrust during the period under review has been 
the establishment of training programs for ophthalmic assistants. 

The Southern African Subregional Ophthalmic Training Center’s 
Regional Eye-Care Training Program in Lilongwe, Malawi, trains 
ophthalmic assistants from all parts of the subregion. To date 135 
ophthalmic assistants have undergone training at the Center. The 
ongoing national training programs in Ethiopia, Kenya, Mozam- 
bique, and Tanzania have also continued to train ophthalmic 
assistants. In 1989, Sight Savers in collaboration with the Uganda 
Ministry of Health, established a national training program for 
ophthalmic assistants. Furthermore, Lesotho and Zimbabwe are at 
an advanced stage of establishing national training programs for 
ophthalmic nurses, with support from Sight Savers and Norwegian 
NGOs respectively. 

Other major achievements include the development of national 
programs, and the NGO support of these programs. Five members 
states in the subregion, Botswana, Lesotho, Mozambique, Swaziland, 
and Zambia, collaborated with the WHO in the collection of data 
on the causes and distribution of blindness and the formulation 
of national programs. Almost all countries in the subregion have 
formed national committees for the prevention of blindness. 

The WHO and international NGOs, in collaboration with 
ministries of health, have organized several meetings that have 
proved useful particularly for the discussion of experiences. On May 
25-29, 1987, Christoffel-Blindenmission and Sight Savers organized 
a meeting in Togo for the trainers of eye health personnel; on 
February 25-26, 1988, the Zambia Ministry of Health, in collabora- 
tion with the IDRC of Canada, organized a seminar on eye diseases 
in Africa and also disseminated the results of the Luapula Valley 
survey of 1985. During March 9-10, 1988, the second meeting of 
the Consultative Group of NGOs to the WHO Program for the 
Prevention of Blindness took place in Nairobi, Kenya, to discuss 
developments of both global and regional impact that are related 
to the work of the WHO program as well as NGO support of the 
IAPB. 

On July 5-8, 1988, the WHO organized a workshop in Accra, 
Ghana, on Manpower Development for Blindness Prevention in 
Africa that focussed on the role of eye health workers at all levels 
in relation to training and service needs within primary health-care 
systems. 

From December 1988 to March 1989, the WHO commissioned 


East, Central , and Southern Africa 47 


short-term consultancies to Botswana, Lesotho, Mozambique, 
Swaziland, and Zambia to collect data on blindness, training needs, 
and formulation of programs. During October 24-28, 1989, the Tan- 
zania Food and Nutrition Center organized a meeting on vitamin 
A deficiency and xerophthalmia to discuss national and regional 
control strategies. From June 24-26, 1990, the Zambia Ministry of 
Health with Helen Keller International organized a workshop on 
Vitamin A deficiency and xerophthalmia for the African Region 
to review national and regional control strategies. 

In addition to regional meetings, two inter-regional meetings 
took place. One on corneal blindness within primary health-care 
systems was held in Tunis, Tunisia, during November 14-18, 1988. 
The meeting reviewed data on corneal blindness, pathways to cor- 
neal blindness, preventive strategies, and role of community par- 
ticipation and health education. 

The twelfth IVACG meeting was held in Addis Ababa, Ethiopia, 
from December 7-11, 1987. During September 25-29, 1989, the East- 
African Health Community and the West-African College of 
Surgeons hosted a subregional workshop on prevention of eye 
diseases and blindness in Banjul, Gambia, to develop African 
Regional control strategies. 

These meetings have resulted in a consensus on priorities for 
prevention of blindness in the subregion. Of the 13 countries in the 
subregion, only two have not yet developed national programs. It 
is particularly noteworthy that the involvement of international and 
national NGOs, including service clubs, is of great importance in 
the African Regional setting, where the scarcity of resources within 
the health sector is becoming more and more serious as a result 
of economic recession. 

In conclusion, the main challenge in the future for prevention 
of blindness in this subregion is to continue strengthening national 
programs. This will require further support from both local and 
international NGOs. 



2 


Regional Progress Report: 

West Africa 

Drs. Daniel Etya’ale and Nicolas Toufic 

BACKGROUND 

The West-African Subregion is a heterogenous area with two very 
distinct subgroups: French-speaking West Africa and English- 
speaking West Africa — and the difference goes far beyond merely 
the speaking of two different languages. Despite these differences, 
the two subgroups share the following: 

1. A high prevalence rate of blindness, over 1.0 percent in many 
areas, with half of these cases of blindness due to cataract, 
plus endemic (and in some parts hyperendemic) onchocer- 
ciasis, which sweeps the entire subregion. 

2. An extreme shortage of ophthalmologists (about 1 ophthal- 
mologist to 1.5 million inhabitants). This shortage is made 
even worse by the fact that most ophthalmologists live and 
work in big cities and not all are capable of performing suc- 
cessful cataract surgery. 

3. Inadequate or nonexistent structures at the national level to 
initiate, promote, coordinate, and supervise the implemen- 
tation of policies and programs pertaining to the prevention 
of blindness. 

4. A worsening economic crisis that severely limits existing funds 
and makes the new reallocation of funds very difficult, if 
not impossible. 

ACCOMPLISHMENTS 
Collection of Basic Data 

A great effort is being made in many parts of West Africa to arrive 
at a more realistic prevalence rate of blindness. 


49 


50 Plenary Session II— I APB Regional Progress Reports 

In 1988, national population surveys were carried out in Togo 
and in the Congo. In other countries, such as the Central African 
Republic, Chad, Gabon, and Zaire, surveys were more limited in 
their scope. However, from these surveys, the prevalence rate was 
estimated at 1.2 percent and the five most common causes of blind- 
ness were found to be, in order: cataract, onchocerciasis, trachoma, 
glaucoma, and Vitamin A deficiency. 


Establishing a National Committee for the Prevention of Blindness 

An increasing number of West African countries have established 
blindness prevention programs. The Gambia, Sierra Leone, Ghana, 
Mali, and others are currently in the process of establishing such 
programs. Preliminary studies have been completed in Togo and 
a national consultation meeting is being convened in Cameroon for 
early January, 1991. 


Introduction and Widespread Distribution of Ivermectin 

Ivermectin, not yet the ideal drug to combat onchocerciasis, is never- 
theless a giant step in the right direction. To date, over 150,000 doses 
have been distributed within the Onchocerciasis Control Program 
(OCP) region. Because of the tolerance that has been recorded, mass 
distribution is recommended. 


Manpower Development 

The severe shortage of ophthalmologists in the West-African 
Subregion remains one of the major obstacles to effective blind- 
ness prevention programs. The present situation of too few 
ophthalmologists is likely to continue for many years and the target 
of 1 ophthalmologist per 200,000 inhabitants still remains a dis- 
tant dream. We hope that this unfortunate situation will be improved 
using lessons learned from experiences in training ophthalmic per- 
sonnel in East Africa. 

Progress in the field of manpower development has been made 
in two main directions. First, two consultations have been convened, 
one for English-speaking West Africa in Accra, Ghana, in July 1988, 
and one for French-speaking West Africa in Lome, Togo, in April 
1990. Both meetings were conducted with a deep commitment and 
resolve to train different categories of ophthalmic personnel. As 


West Africa 51 


a result of the Accra meeting, two training programs for ophthalmic 
nurses have been established with the Ministries of Health in Ghana 
and Sierra Leone. In the Francophone area, the Institute of Tropical 
Ophthalmology in Bamako, Mali, has been reorganized and now 
offers a four-year training course for ophthalmologists and a one- 
year course for ophthalmic nurses. 

Secondly, since 1988 regular in-service training courses varying 
in length from three weeks to three months have been conducted 
in Burkina Faso, Cameroon, Chad, The Gambia, Ghana, Sierra 
Leone, and Zaire. These courses have been run entirely by NGOs, 
particularly Christoffel-Blindenmission. 

Other recent events in the West-African Subregion include: the 
Fourth Congress of the Pan African Society of Ophthalmology in 
Bamako, Mali, in November 1988; the creation of the Central 
African Ophthalmology Society in March 1989 (a special report, 
entitled “Prevention of Blindness in Inter-tropical Africa,” which 
Dr. Nicolas Toufic presented at this meeting is available from Dr. 
Toufic); and a meeting of the Organization for the Prevention of 
Blindness in Mali (Yeelen) in May 1990. 


CONCLUSION 

Something very concrete is taking place in West Africa in the im- 
portant area of blindness prevention. Significantly, this is not the 
result of a few isolated private initiatives, but rather it derives from 
a series of concerted efforts. These efforts must be sustained, en- 
couraged, and better-channelled to further increase efficiency and 
reduce cost. Assuredly, one of the greatest challenges in the com- 
ing years will be to identify, train, and motivate key persons at the 
national level to play the important role of catalyst. 



3 


Regional Progress Report: Peru, Bolivia, 
Ecuador, Colombia, and Venezuela 

Dr. Francisco Contreras 

Central and South America constitute a developing subcontinent 
covering 21 million square kilometers with 450 million inhabitants 
in 37 countries; 32 percent of the population is rural and 68 per- 
cent is urban. The income rate is $1,820. There are 12,000 ophthal- 
mologists. Unfortunately there is an unequal distribution of both 
human and financial resources. 

Since the last IAPB meeting in New Delhi, several NGOs such 
as Helen Keller International (HKI), Operation Eyesight Universal 
(OEU), Christoffel-Blindenmission (CBM) and the International 
Eye Foundation (IEF), have given technical and/or financial sup- 
port to the Prevention of Blindness Programs in different countries 
of the region. We would also like to mention successful vertical pro- 
grams, such as Cataract-Free Zones, which have been developed thus 
far in nine Latin American countries. 

In Andean countries, the activities of ocular health and preven- 
tion of blindness that are conducted through the National Health 
System, are supported by HKI, OEU, and Project Orbis. The Pan- 
American Association of Ophthalmology is playing an increasingly 
important role through its Prevention of Blindness Committee. 

In Peru, a medium-term action plan is being executed with the 
following eight components: 

1. Manpower development and training of personnel. 

2. Training of primary health workers. 

3. Training of supervisory nurses. 

4. Training of general practitioners. 

5. Training of one ophthalmologist in public health at the 
tertiary level. 

6. Implementation of health services by providing minimum 


53 


54 Plenary Session II— I APB Regional Progress Reports 

equipment and medicines to the first and secondary levels; 
in addition, a low-cost spectacles assembly workshop is in 
its pilot project phase. 

7. In operations research: The Cataract-Free Zone projects are 
in their expansion phase. After the experience in Chimbote, 
Peru, and Campinas, Brazil, two new Cataract-Free Zone 
projects were performed in Peru, one on the coast in lea and 
another in the jungle in Iquitos. Both are currently in the 
evaluation phase. 

8. In epidemiologic research: With the technical assistance of 
Operation Eyesight Universal, we are in the planning phase 
of a vitamin A deficiency prevalence survey. The objective 
is to state the magnitude of the problem in order to develop 
future intervention strategies. We are also spreading infor- 
mation through a Spanish bulletin edited with the support 
of Project Orbis and Operation Eyesight Universal. The pur- 
pose of this summary is to disseminate information about 
prevention of blindness programs that have been developed 
in our region. 

A significant blindness problem exists in Latin America with 
a great opportunity to mobilize available resources of manpower 
and technology to combat it. Generally, the governmental national 
health programs are orientated to mother-child programs or to con- 
ditions with high mortality rates. However, with the interest and 
participation of different non-governmental organizations, commit- 
tees of the National Societies of Ophthalmology and the Pan- 
American Association of Ophthalmology, many programs have been 
started and others are being planned in Latin America. 


4 


Regional Progress Report: 

Argentina, Uruguay, Paraguay, and Chile 

Dr. Eugenio Maul 

The one necessary component of all blindness prevention programs 
is the ophthalmologist. However, in most countries of South Amer- 
ica the interest in blindness prevention among ophthalmologists has 
been low. Traditionally the ophthalmologist has been busy per- 
forming research to improve our understanding of eye diseases, 
developing new drugs, or taking care of patients. However, the con- 
tribution of such activities toward the prevention of blindness is 
limited. It is from their involvement in public health that 
ophthalmologists become more productive in the field of preven- 
tion of blindness. 

The following are prevention of blindness meetings stimulated 
by my IAPB activity in the southern cone of South America: 

1. A seminar on blindness prevention strategies in Chile was 
held to inform clinical ophthalmologists and motivate them 
in the field of prevention. It was attended by 192 ophthalmol- 
ogists — nearly 60 percent of all those in Chile. Major causes 
of blindness were discussed and Dr. Caraxo from PAHO lec- 
tured on the concept of visual health status. 

2. The first Argentina meeting on Sanitary Education, Preven- 
tion, and Rehabilitation of the Blind was held in 1987 dur- 
ing the XIII Congress of Ophthalmology in Cordoba. 

3. The first meeting in Uruguay on prevention of blindness was 
held in December 1991, during the Congress of Ophthal- 
mology in Punta del Este. 


BLINDNESS PREVENTION COMMITTEES 

In Argentina, Uruguay, and Chile, prevention of blindness activity 
has originated mainly from prevention of blindness committees 


55 


56 Plenary Session II— I APB Regional Progress Reports 

within the national ophthalmological societies. These departments 
have been very active in promoting many prevention activities and 
also in educating the local ophthalmological community. In 
Paraguay a section in the Ministry of Health promotes primary eye 
care as a way to prevent blindness. 


EPIDEMIOLOGICAL AND CLINICAL RESEARCH COURSES 

This activity sponsored by national ophthalmological societies has 
been directed by Dr. Carl Kupfer with the collaboration of scien- 
tists from the United States and Latin America. Three-day courses 
to a group of 40-50 selected ophthalmologist were given in Argen- 
tina, Brazil, and Chile. These courses have been instrumental in 
epidemiological research related to prevention of blindness. A flow 
of papers on causes of blindness, outpatient consultation, and blind- 
ness in children has followed these courses. 


PRIMARY EYE CARE 

Two studies related to this field, one in Chile funded by a grant 
from PAHO and another in Paraguay funded by AGFUND/PAHO 
are giving important information related to primary eye care as a 
strategy to prevent blindness in this area. Both are using the struc- 
ture of the existing primary health-care system. Besides providing 
first aid to eye patients, it improves the accessibility of the patient 
to eye services. The study in Chile, which is now finished, was con- 
ducted in part in a rural setting and in part in a suburban popula- 
tion, where the primary health physician received primary eye-care 
training. They were able to resolve 55-65 percent of primary eye 
consultations, and of those referred to the ophthalmologist 80 per- 
cent of the cases were referred correctly. These results stress the role 
of primary eye care in blindness prevention. 

DELIVERY OF EYE CARE 

Several institutions provide eye care through programs supported 
by local and also foreign organizations. “Corporation de ayuda al 


Argentina , Uruguay ; Paraguay ; and Chile 57 


limitado visual” in Concepcion, Chile, provides secondary and 
tertiary eye care with the important support of Christoffel- 
Blindenmission. 


OPERATIONS RESEARCH IN PREVENTION OF BLINDNESS 

Dr. Carl Kupfer, Director of the National Eye Institute in Bethesda, 
Maryland, supported the hypothesis that cataract is the main cause 
of blindness in Latin America. This idea was carried on by the Pan- 
American Association of Ophthalmology and Helen Keller Inter- 
national to successfully demonstrate in the two initial Cataract-Free 
Zone projects in Peru and Brazil that cataracts are indeed the most 
important cause of blindness in the region. In the second phase, 
10 projects were initiated, and three of them have been completed, 
two in Chile (one in a rural area and another in an urban area) and 
one in Uruguay. These three projects were able to replicate previous 
findings that half of the blindness in these countries may be cured 
by a cataract operation. 

These projects have been also important for motivation of the 
ophthalmological community and have also served as a demonstra- 
tion for health authorities, who are often busy with other problems, 
such as childhood mortality, which are of the magnitude and im- 
portance of blindness. Cataract-Free Zone projects can also prove 
that much can be done using existing facilities and human resources. 


LIONS’ SIGHTFIRST PROGRAM 

The impact of the cataract program has been great. As a conse- 
quence, recently the SightFirst Program, an initiative in prevention 
of blindness by the International Associations of Lions Clubs, has 
considered cataract blindness a priority and has launched a series 
of projects in Latin America that includes Mexico, Venezuela, 
Colombia, Ecuador, Peru, Chile, Uruguay, and Argentina. These 
projects will include treating the cataract blind and providing 
eyeglasses to those persons who will benefit. 

Epidemiological data on prevention of blindness have also been 
a product of these activities. It is clear that for countries like Argen- 
tina, Chile, Paraguay, and Uruguay the principal causes of blind- 
ness are cataract, glaucoma, diabetic retinopathy, other retinal 


58 Plenary Session II— I APB Regional Progress Reports 

disorders, and trauma. Childhood blindness in these countries is 
due to prenatal causes in 60 percent of the cases. Such information 
is of foremost importance for future activities in the field of blind- 
ness prevention. 

Finally, I wish to recognize the support of Merck Sharp and 
Dohme, Chibret International in my activities as Co-chairman for 
South America (Argentina, Chile, Paraguay, and Uruguay). 


5 


Regional Progress Report: 

Central America 

Dr Fernando Beltranena 

The Central American Subregion includes seven countries: 
Guatemala, Belize, Honduras, El Salvador, Nicaragua, Costa Rica, 
and Panama. Except for Belize (officially English), all are Spanish- 
speaking countries. In addition, there is a large population in 
Guatemala who speak Indian languages, making communication 
sometimes difficult. 


GEOGRAPHIC OVERVIEW 

Central America forms an arc between the Yucatan Peninsula and 
South America. It is a corridor between two continents and holds 
a convenient passage between two oceans. Nature divided the land 
into warm lowlands and cool mountain uplands. The climate allows 
a wide variation of vegetation, from mangrove swamps to pine groves 
and from savanna to rain forest. 

Central America presents a mosaic of peoples: Indians with 
language and customs inherited from their pre-Columbian ancestors, 
descendants from the Spanish conquistadors, and immigrants from 
Europe and other places. Its area is 5,227,650 square kilometers and 
its population is 25,300,000. 

Unfortunately, political turmoil in some of the Central American 
countries makes data collection very difficult. Reports on activities 
on prevention of blindness in each country are scarce and sometimes 
impossible to get. 

Prevention of blindness activities have been important in 
Guatemala for a long time. Guatemala is a small country with an 
area of 109,000 square kilometers. 

The country is divided into 22 departments and 328 municipal- 
ities or counties. It has a population of 9.6 million, 45 percent of 


59 


60 Plenary Session II— I APB Regional Progress Reports 

whom live in urban areas and 55 percent of whom live in rural areas, 
with a population density of 88 per square kilometer. The crude 
birth rate is 40 per 1,000, and the fertility rate shows that the average 
woman has five or more children. Guatemala has a per capita in- 
come of $100 per year. Inflation has risen 100 percent in the last 
year. The public health budget is 8.7 percent. 


BLINDNESS AND OCULAR MORBIDITY SURVEY 

A survey, made in the highlands in 1986 with the joint efforts of 
the World Health Organization and the National Committee for 
the Blind, showed the following data: visual acuity of less than 
20/400 (0.11 percent), acuity of less than 20/200 (2.00 percent), and 
acuity of less than 20/100 (7.11 percent). 

Data regarding the etiology of ocular morbidity showed the 
following: trachoma (36 percent), refractive defects, including 
amblyopia (22 percent), cataracts (21 percent), retinal disease (9 per- 
cent), corneal opacities (7 percent), and glaucoma (5 percent). 


ONCHOCERCIASIS 

Data on onchocercosis in Latin America shows: Guatemala (40,000 
cases, 600 blind), Mexico (24,000 cases, 100 blind), Venezuela (20,000 
cases, 100 blind), and Ecuador (7,000 cases, 100 blind). In Guate- 
mala, onchocerciasis is primarily distributed in the zones on the 
south slope of the mountain chains between 1,000 and 5,000 feet. 
These zones are forest-covered areas of coffee plantations with high 
trees that give adequate shade to the plantation. Small rivers and 
mountain streams provide breeding sites for the transmitting flies. 

Since Dr. Azis studied the microfilaricidal effect of Ivermectin 
in 1982, careful follow-up studies in Africa and Guatemala have 
shown the efficiency and safety of the drug for human use. In 1988, 
the Onchocerciasis Department of the Ministry of Health of 
Guatemala, headed by Dr. Guillermo Zea-Flores, started a pilot 
study in a population of 3,000 skin-positive and nodule-positive 
patients. Their results showed not only the safety of the product, 
with only 25 percent experiencing light to moderate reactions, but 
also the feasibility of stopping transmission by giving a simple dose 
of Ivermectin every six months instead of once a year. 

The Dr. Rodolfo Robles Eye Hospital of the National Committee 


Cen tral A m erica 6 1 


for the Blind and Deaf, in association with the International Eye 
Foundation, and with the financial support of the Public Welfare 
Foundation, and in coordination with the Ministry of Health, started 
the first mass-distribution project of Ivermectin in the Western 
Hemisphere in 1990. 

The area assigned by the Director of the Onchocerciasis Divi- 
sion of the Ministry of Health was the Yepocapa Municipality, an 
endemic area of 71 villages or specific locations in the Department 
of Chimaltenango. It had a target population of 19,000 inhabitants 
and an eligible population of 12,000. We have followed the rec- 
ommended exclusion criteria: pregnant women, lactating women 
within one month of delivery, weak or seriously ill persons, and 
small children (under 15 kilograms of weight) are not allowed to 
participate. 

As of October 1, 1990, we had given the Mectizan dose to 8,500 
persons. We have covered 80 percent of the targeted population. 
By the first week in December 1990 we will have finished with the 
last village. From the projection that we have been able to make, 
we believe that the ultimate coverage will be over 85 percent of the 
population. 

A motivated population, in addition to the nodulectomies, can 
contribute to positive results. The International Eye Foundation has 
already requested funds for the second-year of treatment. We in- 
tend to involve the health promoters of the area to increase the treat- 
ment in nearby localities and extend our coverage to some 25,000 
patients. The program in Yepocapa has funding for up to three years. 
We will rely on local resources to continue the Ivermectin treatment 
if international funds become unavailable. This program also re- 
quires the availability of the drug from Chibret International. 

For the last three years, Ciba has been conducting clinical 
research with their onchocercacide drug CGP 6140 in Ecuador and 
Guatemala. In Guatemala the Dr. Rodolfo Robles Hospital has pro- 
vided the territory used for the drug trials. Amocarzine (CGP 6140) 
is a colored agent developed as an oral microfilaricide. It also 
possesses good microfilaricidal properties when used in humans. 
The drug is given after meals in a regimen of three mg/kg twice 
a day for three consecutive days. It has been shown that post- 
prandial administration provides higher and more regular plasma 
levels. 1 


62 Plenary Session II— I APB Regional Progress Reports 

TRACHOMA PROJECT IN GUATEMALA 

The Blindness and Ocular Morbidity Survey in Guatemala showed 
that in 1986 trachoma represented 7 percent of the pathology found 
in the highland population. Through the initiative and partial fun- 
ding of the WHO, we have finished the third phase of a program 
to train health personnel in the new Simplified Grading System for 
Trachoma. We started the project in November, 1989, and have 
covered three departments and a total population of 671,000 people. 
We have had the full cooperation, coordination, and integration 
of personnel from the Ministry of Health. We have trained 45 physi- 
cians and directors of health centers, 75 health technicians, and 580 
voluntary community-based health promoters. After receiving 
reports from the endemic areas, we have been able to deliver ter- 
ramycin ointment donated by Christoffel-Blindenmission. 

Reports from the Solola area show that more than 5,000 cases 
of mostly follicular, inflammatory, or scar trachoma have been 
detected. Epidemiological reports from the health promoters and 
technicians are still coming. The facts shown on these reports have 
caused the head of the Solola area to reconsider the official view 
of trachoma and to include this disease among the priorities of the 
health authorities in the area. 


VITAMIN A PROGRAM 

Nutritional studies by INCAP (Central American Institute of Nutri- 
tion), CESSIAM (Investigative Branch of the National Committee 
for the Blind, and the Dr. Rodolfo Robles Hospital) show a high 
degree of malnutrition and hypovitaminosis A of the population 
in Guatemala. This is a national problem necessitating the mobiliza- 
tion of a multi-institutional intervention program. 

The National Commission for Vitamin A was created with the 
participation of UNICEF, INCAP, the Ministry of Health, the Na- 
tional Committee for the Blind, the National University of San 
Carlos, and AZAGUA (Sugar Mills Association of Guatemala). This 
committee has been working since 1988 to carry out a program in 
three phases to reduce the hypovitaminosis A in children under six 
years of age. The target population constitutes 6 million children. 

Phase one of this program includes delivery of a prophylactic 
dose of 200,000 units of Vitamin A per child to a wide range of 
the population. Phase two seeks to fulfill the goals of sugar for- 


Central America 63 


tification. Finally, and most importantly, phase three attempts to 
increase production and consumption of carotene-rich foods by the 
population. 

CESSIAM has been performing research on several aspects of 
the nutritional status of the population and nutrient trials (including 
vitamin A trials) in some areas of Guatemala. 


RESIDENTS IN OPHTHALMOLOGY PROGRAMS 

Guatemala is the only country in Central America where a full 
university-endorsed resident training program exists. There are two 
programs, the first is government and state financed and endorsed 
by San Carlos University at the Roosevelt General Hospital. The 
second is a program of the Dr. Rodolfo Robles Hospital and is en- 
dorsed by Francisco Marroquin University, a private Institution. 
There are 36 residents in both programs. Both residency programs 
provide scholarships for foreign residents. Colombia and Ecuador 
have the largest populations of resident alumni of the Guatemalan 
programs. From Central America there are residents of Belize, Hon- 
duras, El Salvador, and Nicaragua. 

Since 1988, groups of about 300 medical students have been 
trained in primary eye care in an eight-hour course delivered at the 
Dr. Rodolfo Robles Hospital. The students attend the course prior 
to rotating through the health clinics and centers that the Medical 
School of the University of San Carlos maintains in rural and 
poverty-stricken areas. 


HEALTH PERSONNEL TRAINING 

Physicians, nurses, health technicians, and health promoters, total- 
ling more than 600, have attended the primary eye-care courses pro- 
vided in rural areas by the Dr. Rodolfo Robles Hospital. In the area 
of surgical and medical ophthalmology for nurses, fifty students 
from the National Nurse School have received a year of training, 
which includes courses in primary eye care. 


NGOs IN THE PREVENTION OF 
BLINDNESS IN CENTRAL AMERICA 

The International Eye Foundation, which has several projects and 


64 Plenary Session II— I APB Regional Progress Reports 

programs in Guatemala, Honduras, and Belize, has implemented 
an Eye Clinic in Santa Rosa, Honduras, and also in Belmopan. Mass 
distribution of Ivermectin in association with the National Com- 
mittee for the Blind is taking place in Guatemala, and nutrient 
distribution to school children in three rural areas is ongoing in 
association with the NCFB. In addition, scholarships for ophthal- 
mologists help provide eye care to the area of Santa Rosa in 
Honduras. 

Christoffel-Blindenmission, which has given equipment and in- 
struments for eye surgery, direct aid to poor patients, visual aids, 
and therapeutic contact lenses to Guatemalans, also has provided 
20,000 tubes of terramycin for the trachoma program at the Dr. 
Rodolfo Robles Hospital of the NCFB. Vision for the Americas, 
Inc. has donated equipment and instrumentation to the National 
Committee for the Blind in Guatemala and has helped to establish 
eye clinics. In addition, Project Orbis has conducted hands-on 
teaching for residents in ophthalmology and has donated drugs and 
teaching visual aids. 


REFERENCE 

1. Poltera AA, Zea-Flores G, Guderian R, Beltranena F, et al. 
Onchocercacidal effects of amocarzine (CGP 6140) in Latin 
America. Ciba-Geigy, Switzerland. Lancet 1991 Mar; 337(8741): 
583-4. 


6 


Regional Progress Report: North America 

Mrs. Virginia Boyce and Mr. John M. Palmer ; III 

North America includes the nations of Canada and the United 
States, and has a combined population of 300 million. There are 
15,000 ophthalmologists in the region, providing a ratio of 1 oph- 
thalmologist for every 20,000 people. 

It is estimated (East Baltimore Survey) that in North America 
there are 1 million blind persons resulting from the following causes: 

1. Unoperated Cataract. (As in other places, despite huge in- 
creases in cataract operations, there is an uneven access and 
utilization of care; cataract is responsible for 30 percent of 
all blindness in Blacks.) 

2. Open-angle glaucoma in the Black population and age-related 
macular degeneration in Whites. 

3. Diabetic Retinopathy. 

The immediate challenges in blindness prevention in North 
America are: 

1. To make cataract surgery accessible and usable by all who 
need it. Not only blindness should be eradicated, but also 
visual impairment (worse than 20/40), so that people can 
read comfortably, retain their jobs, and have regular drivers 
licenses. 

2. To develop better methods of identifying people with glau- 
coma. Only one half of those who have glaucoma presently 
know it. We must identify them before they inevitably become 
blind. Target screening should be performed for the highest 
risk groups: Blacks, the elderly, and those with a positive 
family history. 

3. To make certain all diabetics receive annual eye examina- 
tions, and to treat visual impairing and blinding retinal 
changes. Therapy is very effective, but people need regular 
examinations. 


65 


66 Plenary Session II— I APB Regional Progress Reports 


Although this report briefly summarizes conditions within the 
North American region, our focus is primarily directed outside 
Canada and the United States. 

During the past quadrennial, the North American region has 
reconstituted itself and enlarged its membership. International non- 
governmental organizations included are: Seva; The International 
Eye Foundation; Project Orbis; Helen Keller International; Sight 
Savers; Combat Blindness, Inc.; and Christoffel-Blindenmission, 
USA. In addition, we look forward to welcoming the River Blind- 
ness Foundation in the near future. The American Optometric 
Association, the American Academy of Ophthalmology, the Pan- 
American Association of Ophthalmology, and the International 
Vitamin A Consultative Group are also represented at regional 
meetings, as are links with WHO Collaborating Centers such as 
the National Eye Institute at the National Institutes of Health and 
the International Center for Epidemiologic and Preventive Oph- 
thalmology at the Johns Hopkins School of Hygiene and Public 
Health. 

The North American Subregion has met annually at the Na- 
tional Institutes of Health for the purpose of information sharing, 
planning, and support. Of special note, the subregion co-hosted a 
major conference on blindness prevention with emphasis on cataract 
surgery in conjunction with the tenth Anniversary of the World 
Health Organization’s Prevention of Blindness Program. 

The focus of the North American Subregion is to develop ef- 
fective strategies for supporting and expanding blindness preven- 
tion activities in the field. To do this, we are achieving new levels 
of collaboration and cooperation which include a newly established 
computer-linked communications system (with assistance from the 
American Academy of Ophthalmology) that builds towards more 
efficient use of commodities and gifts-in-kind and collaborative 
interagency programming. This has been most recently illustrated 
by the formation of a North American consortium to address the 
disastrous effects of river blindness. 

Looking to the decade of the 1990s, we are challenged to achieve 
new levels of support for the expanded program opportunities before 
us and to design even more effective strategies for achieving the im- 
proved and sustainable impact of those local and national programs 
with whom it is our privilege to collaborate. 


7 


Regional Progress Report: 

Eastern Mediterranean 

Sheikh Abdullah M. Al-Ghanim 

INTRODUCTION 

I have the pleasure and honor to participate in the IAPB Fourth 
General Assembly, which represents a new constructive and serious 
step in coordinating and integrating the control and prevention of 
blindness. This gathering, I believe, will be an excellent opportun- 
ity for specialists and persons concerned with protecting vision to 
exchange views and experiences and discuss scientific and human 
aspects pertaining to this subject. 

I would like to extend my heartfelt thanks and appreciation to 
the Republic of Kenya for hosting this conference and to Dr. Carl 
Kupfer for his kind invitation to participate and speak at this impor- 
tant Assembly. On this occasion, I should express my appreciation 
of the IAPB’s active contribution to the prevention of blindness 
and the control of eye diseases all over the world. We are extremely 
proud of the excellent work of this Agency. 

This report will deal with different subjects, achievements, and 
aspects concerning the prevention of blindness in this region. To 
portray a clear picture on these issues, it may be useful to divide 
this report into different sections. 


MAGNITUDE OF THE PROBLEM OF BLINDNESS 

Blindness continues to be a major health and social problem in most 
countries of the Eastern Mediterranean Region. But despite this fact, 
until now, it has not been possible to estimate accurately the number 
of blind persons in the region, both because information is lacking 
and because each country defines blindness in relation to its own 
social and economic conditions. Therefore, the magnitude of the 


67 


68 Plenary Session II— I APB Regional Progress Reports 

problem is still not know in its details and dimensions. This scarcity 
of data causes major difficulties encountered in the region. 

However, according to the statistics available in this field, a rough 
estimate for the region would be 8 million blind people in 1990. 
More than 75 percent of blindness in the countries of the region 
is believed to be preventable. This represents a region-wide prevalence 
rate of about 2.5 percent. According to some investigations, it is 
estimated that most national prevalence rates have now become 
about 1. 0-2.0 percent, as a result of improved health care and health 
services, especially in the field of eye-care systems and prevention 
of blindness in many countries of the region. 

In areas of the region free from trachoma, onchocerciasis, and 
other acute eye problems, the prevalence of blindness is less. Rates 
may vary from 0.86 percent in such areas to 4.2 percent in those 
places where such causes are endemic. In accordance with estima- 
tions and statistics, we have received recently from some countries 
in the region. The blindness rate in Saudi Arabia is 1.5 percent, in 
Iraq it is 1.0 percent, Qatar has 1.8 percent, Jordan has 1.6 percent, 
Egypt has 1.8 percent, and Tunisia has 1.9 percent. In the Arab Gulf 
Area, the blindness percentages fluctuate between 1.0 percent and 
2.0 percent. However, in rural areas the percentage may be higher. 

These figures indicate the serious magnitude of the problem of 
blindness, which necessitates joint efforts for the control of blind- 
ing diseases as well as the need for the provision of an intensive 
program of education, rehabilitation, and employment. Although 
most of the countries in the region have made great efforts to pre- 
vent unnecessary blindness, unfortunately the problem is still severe. 
This is in our opinion due to the following reasons: 

1. Delay of ophthalmological attention and care for patients 
suffering from eye diseases. 

2. Lack of a practical program for prevention of blindness, as 
well as a national policy for the control of communicable 
eye diseases. 

3. Lack of accurate and up-to-date statistics. 

4. Lack of skilled medical manpower. 

5. Lack of specialized ophthalmological services, especially in 
remote and rural areas. 


Eastern Mediterranean 69 


MAJOR CAUSES OF BLINDNESS 

Causes of blindness in the Eastern Mediterranean Region appear 
nearly similar to those in the other regions in the world. They are 
as follows: 


Trachoma 

Trachoma is still considered one of the principal causes of blind- 
ness in the region. About 150 million people are liable to be afflicted 
by eye diseases, especially trachoma. More than 60 percent of these 
cases could be prevented by good hygiene and early treatment. The 
majority of preventable cases occurs in children. Although vigorous 
national efforts have been exerted in many countries of the region 
over the past several years to eradicate this eye disease, trachoma 
is still not under control. 

Cataract 

Cataract is also one of the leading causes of blindness in many coun- 
tries of the region, especially among old people. As the aging popula- 
tion increases, cataract is going to be the major target for preven- 
tion of blindness programs in the Kingdom of Saudi Arabia. 
Cataracts are already responsible for 55 percent of the blindness 
in the Kingdom. 


Trauma 

Trauma is the most important preventable cause of blindness among 
school-age children in all countries of the region. In agricultural 
areas even minor injuries to the cornea may lead to blindness by 
infection. Prevention of minor injury is therefore important to 
prevention of blindness. In addition, special attention should be 
given to the rapid industrialization occurring in the region during 
recent years because such development often leads to increased 
workplace accidents that cause blindness. 


Other Causes 

Other causes of blindness are attributed to glaucoma, car accidents, 
conjunctivitis, onchocerciasis, and refractive problems. Among other 


70 Plenary Session II— I APB Regional Progress Reports 

causes of blindness in some countries of the region, complications 
resulted from abuse of dangerous drugs without medical consulta- 
tion or supervision, plus complications resulting from the use of 
popular prescriptions in treating or beautifying the eyes (e.g. Al- 
Kohl) according to the unhealthy social customs which we must 
eliminate from the region. 


SUGGESTED PROGRAM FOR PREVENTION OF BLINDNESS 

Although great efforts have been exerted by most of the region’s 
countries, prevention of blindness is still surrounded by many serious 
problems. The Eastern Mediterranean Region recognizes that these 
problems cannot be solved by individual actions, but require cooper- 
ation, coordination, and collaboration. The critical need is to for- 
mulate a general program for prevention of blindness in each country 
at the national level. 


ACTIVITIES OF THE EASTERN MEDITERRANEAN REGION 
IN THE FIELD OF PREVENTION OF BLINDNESS 

I am pleased to review in brief some activities carried out by the 
Eastern Mediterranean Region in the field of prevention of blind- 
ness since the Third General Assembly of the I APB in New Delhi, 
India, in December 1986. 

Since its establishment, the Eastern Mediterranean Region has 
been intent on investigating effective methods and techniques of 
control and prevention of blindness in the Middle East. It has 
worked ceaselessly to halt the widespread prevalence of eye diseases, 
especially those in remote areas where there is a lack of appropriate 
medical services. It has encountered the problem of eye diseases 
and their consequences and affirmed the necessity to prevent them. 
Therefore, it has exerted all efforts to prevent blindness and urged 
all of its members in the region to collaborate with IAPB and WHO 
and with national organizations in the development of practical ac- 
tion for saving and restoring sight. We have continued our coopera- 
tion and coordination with such local and world organizations to 
eliminate the chief causes of blindness in the region, and we have 
brought experts and specialists to conduct surveys on eye diseases 
in order to obtain the most accurate data and best results in the 
field of prevention of blindness. 


Eastern Mediterranean 7 1 


I am pleased to mention here that the Eastern Mediterranean 
Region supports and promotes the activities of the Saudi Ophthal- 
mological Society in Saudi Arabia. Such activities include con- 
trolling and preventing common eye diseases and eradicating 
trachoma in particular as well as disseminating awareness among 
people with regard to eye care, sight protection, and by implanting 
sound health habits by holding seminars, delivering lectures, and 
providing other information. In 1987 and 1988, we have financed 
two awareness symposiums conducted in two provinces in the 
Kingdom of Saudi Arabia by the Saudi Society. 

The Eastern Mediterranean Region in cooperation with the 
World Blind Union and with the Committee on Save Your Sight 
in Bahrain has issued 6,000 copies of a booklet entitled “Save Your 
Sight” in both English and Arabic. These books were distributed 
within the countries of the Middle East to make people aware of 
common eye diseases and the best ways to protect their sight. We 
have also produced a special video film for promoting hygienic 
awareness, eye care, and prevention of blindness. One thousand 
copies of this film were produced and distributed to the schools, 
health centers, universities, and institutions within the Middle East. 

As IAPB Chairman for the Eastern Mediterranean Region, I 
have participated in symposiums held by WHO in Amman, Jor- 
dan, and Alexandria, Egypt, as well as the 37th Session of the WHO 
Regional Committee for the Eastern Mediterranean held in 
Damascus, Syria, in October 1990. 

PREVENTION OF BLINDNESS IN SAUDI ARABIA 

During recent years, Saudi Arabia has witnessed tangible progress 
in all aspects of protecting eyesight and controlling blindness. These 
advances have been the result of considerable development in the 
availability of health services and increases in the number of 
ophthalmologists, eye departments, and specialized eye hospitals. 

Being aware of the importance of prevention of blindness ac- 
tivities, Saudi Arabia set out to establish eye health as one of its 
priority health programs and to take urgent measures in all provinces 
to offer proper services in the field of eye care. In addition, Saudi 
Arabia is doing its best to minimize the number of blind cases, as 
well as to reduce preventable and curable blindness to the low- 
est possible level, and to provide essential eye care to the most- 
deserving cases. 


72 Plenary Session II— I APB Regional Progress Reports 

AVAILABLE STATISTICS 

The number of hospitals in the Kingdom of Saudi Arabia is 156 
with a bed capacity of 25,918. The total number of physicians is 
12,617. The number of ophthalmologists in the Ministry of Health 
is 238; and the number of health centers is 1,668. As for special- 
ized care, the Ministry of Health has two eye hospitals, one in 
Medina with a bed capacity of 54 and the other in Jiddah with a 
bed capacity of 112. There is also an advanced center for preven- 
tion of blindness and low vision in the Eastern Province. There are 
49 eye sections in the central and general hospitals. The total number 
of beds for eye care is 895. There are also eye departments in the 
University and Military Hospitals. In addition, the Kingdom has 
established a modern specialized eye hospital in 1962, the King 
Khalid Eye Specialist Hospital, with a bed capacity of 263. The 
hospital also includes a regional training and research eye center 
for eye care and prevention of blindness. 


SITUATION ANALYSIS 

There are no exact or reliable statistics and information about the 
blind in the Kingdom as a whole, but estimations indicate 1.5 per- 
cent of the total population are blind. If we consider the popula- 
tion to be 8 million, then the number of blind people will be 120,000 
persons. Cataract and trachoma are considered to be the major 
causes of blindness in the country. Available statistics in 1984, denote 
that 22 percent of the population are suffering from either active 
or inactive trachoma. This is in addition to other causes of blindness 
such as glaucoma, corneal ulcers, refractive errors, and various kinds 
of accidents. 

During the years 1983-84, efforts were continued for the develop- 
ment and implementation of national programs for the prevention 
of blindness. One of the most important efforts in this field is the 
national survey on eye diseases and visual impairment, which was 
completed in 1984 under the auspices of the King Khalid Eye 
Specialist Hospital in Riyadh. 

The main objectives of this field survey are: to define the 
magnitude of blindness and eye disease in the Kingdom, to identify 
the major causes of blindness and visual loss, to assess the present 
resources for the delivery of eye care, and to formulate a program 
for preventive and curative action. A nationwide stratified random- 


Eastern Mediterranean 73 


cluster sample survey was carried out during the spring of 1984. 
In all, 16,810 Saudis from 15 metropolitan and 60 non-metropolitan 
segments were examined. This revealed a blindness rate of 1.5 per- 
cent within category 3 of visual impairment or worse. Visual im- 
pairment of from less then 6/18 to 3/60 affected 7.8 percent of the 
population. Visual impairment and blindness increase dramatic- 
ally with age and are notably higher in females. These figures show 
a significant reduction from the previous estimate of 3.0 percent, 
which is in keeping with the improved socioeconomic and health 
standards in the Kingdom. 

The leading causes of blindness according to this survey are: 
cataract (55.1 percent); trachoma (10.1 percent); corneal scars (9.1 
percent); refractive errors (9.0 percent); iatrogenic disorders (4.6 per- 
cent); and glaucoma (3.0 percent). The leading causes of visual loss 
(blindness and visual impairment as defined above) are: refractive 
errors (46.0 percent); cataract (35.0 percent); trachoma (6.0 percent); 
and corneal scarring, iatrogenic, and congenital diseases. Trachoma 
has greatly decreased from previous estimates of a prevalence of 
90.0 percent in the country, with an overall prevalence of 6.2 per- 
cent with active trachoma and 16.0 percent with inactive trachoma, 
and moderate to severe trachomatous inflammation in 1.5 percent 
of the population. 


CATARACT 

With regard to cataract, which is responsible for 55 percent of the 
leading causes of blindness in Saudi Arabia (1984 Survey), the Saudi 
Ministry of Public Health has organized a comprehensive plan to 
fight against cataract through health centers, particularly primary 
health-care centers. This plan includes carrying out general surveys 
in the affected areas for early detection of cataract cases, and then 
referral to the assigned centers for surgical operations. In addition 
to eye hospitals, 20 eye wards or sections were opened in 20 central 
hospitals to receive the referred cases and carry out cataract opera- 
tions for them. Statistics of 1990 indicate that the number of cases 
of cataract operations in eye sections and hospitals in Saudi Arabia 
reached 15,000, which resulted in decreasing the number of cases 
of blindness by 3,000 cases per annum. 


74 Plenary Session II— I APB Regional Progress Reports 

TRACHOMA 

The Ministry carried out a general medical survey of blinding 
diseases with special focus on trachoma in the Eastern Province 
during December 1989 and January 1990. Experts from WHO, King 
Khalid Eye Specialist Hospital, and King Faisal University have par- 
ticipated in the survey. The Eastern Province was selected due to 
the high percentage of blindness that was reported there in the 1984 
Survey, reaching 3.5 percent in comparison to 1.5 percent in Saudi 
Arabia as a whole. 

A comparison of 1984 findings with those of 1990 revealed the 
following: 

1. Decrease of blindness rate from 3.3 percent in 1984 to 1.5 
percent in 1990. 

2. Decrease of trachoma cases from 11.3 percent in 1984 to 1.5 
percent in 1990. 

3. Decrease of trachoma as a major cause of blindness from 
16.5 percent in 1984 to 3.9 percent in 1990. 


RETINOPATHY OF PREMATURITY 

In cooperation with the Ministry of Public Health and King Saud 
University, the King Khalid Eye Specialist Hospital started a full- 
scale study of retinopathy of premature babies. The study resulted 
in the establishment of a clinic for treating and preventing this 
disease. Cases from all areas of the Kingdom will be referred to 
this clinic for treatment. 

According to these achievements, the aspirations of the Ministry 
of Public Health aim at reducing the rate of the low vision and 
blindness in the Kingdom to a degree less than 5 percent in a five- 
year period. 


CONCLUSIONS 

There is an urgent need for formulating a national policy and a 
comprehensive long-term plan in every country. Mass treatment cam- 
paigns and extensive health education programs should be the main 
tools in rural areas. Mobile eye units instead of stationary service 
may be more effective at this stage. Priority should be given to 
primary eye care, which is a vital component of primary health care. 


Eastern Mediterranean 75 


It also should be included in the promotion of eye health and 
in the prevention and treatment of conditions that may lead to 
visual loss. 

Finally, I thank you all, wishing for your General Assembly every 
success. 



8 


Regional Progress Report: Europe 

Gen. Marcel Chovet 

European Partners for Blindness Prevention (EPBP), an associa- 
tion of NGOs working in developing countries, has been formed 
to establish a unified presentation of blindness prevention activities 
to the European Community. The partners consist of Christoffel- 
Blindenmission, Organization Nacional de Ciegos de Espana, 
Organisation pour la Prevention de la Cecite (OPC), Oeil sur les 
Tropiques, Stichting Blindheidbestrijding Ontwikkelingslanden, and 
Sight Savers. The first coordinated program for which co-funding 
is being sought from the European Community is the distribution 
of Ivermectin to be used against river blindness in Africa. 

Although the low incidence of blindness in western Europe may 
be an extenuating factor, ironically it appears that more is known 
about the epidemiology of blindness in many developing countries 
than some of those in the European Region. In France, OPC has 
taken several initiatives in stimulating epidemiological studies, in- 
cluding the provision of an annual award for doctors working in 
this field. In addition, a recent survey in the region of the Rhone 
has categorized the following causes of blindness and partial- 
sightedness: cataract, myopia, trauma, glaucoma, and diabetes. 

The national blindness prevention committee in the United 
Kingdom, the British Council for the Prevention of Blindness, from 
an annual input of $160,000, has contributed to ophthalmic research 
within a number of centers in the United Kingdom. In addition, 
the Council has worked with the London-based International Centre 
for Eye Health to promote training of ophthalmic personnel in 
developing countries. 

Germany’s National Council for the Prevention of Blindness 
has been active in developing countries as well as at home. In Ger- 
many it has been concerned with studies into the incidence of 
glaucoma and diabetic retinography and, notably, has achieved a 
strong working relationship between the Munich University Ophthal- 
mic Department and the ophthalmic program operating in Kenya. 


77 


78 Plenary Session II— I APB Regional Progress Reports 

There is a great need for support from Western Europe for the 
development of community ophthalmic services in East and Cen- 
tral European countries. There is a dearth of equipment available 
to specialists in these underdeveloped countries, and a great need 
for dialogue under the aegis of the IAPB between developed and 
developing European countries. 

I wish to conclude this report with recommendations for ex- 
pansion of the membership of EPBP, the furtherance of 
epidemiological studies throughout Europe, and increased collabora- 
tion among all European ophthalmic departments and non- 
governmental organizations. 


9 


Regional Progress Report: 

South-East Asia 

Dr R. Pararajasegaram 

INTRODUCTION 

The Region of South-East Asia is the second largest WHO Region 
and comprises 11 countries ranging from India, the second most 
populous country in the world to the Republic of Maldives with 
a population of just over 200,000. The 11 countries belong to the 
category of developing countries, and five are classified as least 
developed countries. The total population of the region amounts 
to over 1.3 billion with an under-5 population of 15 percent and 
an over-55 population of 128 million. The average growth rate of 
population in the region is approximately 2.2. There is, however, 
an age differential in this growth of population. It is projected that 
the over 55 population will increase significantly in the next 30 years. 
This demographic trends will have grave implications on our ef- 
forts to combat blindness, given the fact that age-related conditions 
such as cataract, glaucoma, and even posterior segment diseases 
like diabetic retinopathy and retinal and senile macular degenera- 
tions are already causes of concern. 


MAGNITUDE OF BLINDNESS AND VISUAL IMPAIRMENT 

Most countries have fairly reliable data on the prevalence of blind- 
ness and the incidence of blinding disorders. Some (Nepal, India, 
Thailand, and Indonesia) are based on national surveys. Others (Sri 
Lanka, Bangladesh, Maldives, and Bhutan) use more localized or 
hospital-based data. It must be remembered that national averages 
could be misleading because there is wide variation within coun- 
tries. Prevalence rates ranging from 0.2 percent in Mongolia to 3.0 
percent in some parts of Myanmar (Burma) have been reported. 

Over 50 percent of all blindness is due to cataract and it is 


79 


80 Plenary Session II— I APB Regional Progress Reports 

estimated that there are 10-14 million persons blind (vision of less 
than 3/60 in the better eye with best correction) from cataract alone. 
The South-East Asia Region also has the largest incidence of 
childhood blindness, with xerophthalmia being the major etiological 
factor. It is estimated that one child goes blind every minute in the 
world. This rate occurs primarily in Bangladesh, and in some parts 
of Indonesia, Nepal, and India. Blinding trachoma is of concern 
perhaps only in parts of Myanmar and in small pockets in Nepal 
and India. The problem of visual impairment from refractive errors 
is of increasing concern in most countries because of the impact 
it has on the educational process in children and young adults, and 
the unavailability or high cost of the available glasses. Other causes 
of blindness such as angle closure glaucoma in Myanmar and 
climatic droplet keratopathy in Mongolia are generally more local- 
ized problems. Ocular trauma and corneal infections are leading 
causes of monocular visual loss in nearly all countries. 

PROGRESS IN PERIOD OF REVIEW (1987-90) 

The period of review has been a period of turmoil on many fronts 
in a large number of the countries in the region. Global events have 
had severe repercussions on economic growth. This lack of growth 
has had a negative effect on the development of health and social 
programs, which often bear the greatest brunt of these fallouts. 

Despite this rather depressing scenario, it gives me pleasure to 
record the strides that have been made in activities for the preven- 
tion of blindness and the restoration of vision in nearly all countries 
of the region. It is fortunate that representatives from eight of these 
countries are present at this Assembly and have the opportunity 
to share their experiences and achievements with us during this week. 
Drs. S.R.K. Malik and Rajendra Vyas, who have worked with me 
on the Indian National Program, will deal specifically with that 
Program and the role of the non-governmental organizations. I 
might add that Dr. Vyas has shown commendable leadership 
qualities and dedication for more than two decades during his close 
association with the Royal Commonwealth Society for the Blind. 

I will confine my statement to a general overview of the eye- 
care activities in the region as a whole. At the outset I would point 
out that these achievements have come from a close collaboration 
between national government programs, intergovernmental organiza- 
tions (such as WHO, UNDP and UNICEF), and a number of 


South-East Asia 81 


international and national NGOs, including bilateral and other fund- 
ing agencies. Working with the common objective of preventing and 
controlling blindness and providing eye care, these sectors have often 
merged their resources and shared their experiences and expertise. 
Except for specific projects, it is not possible to single out individual 
inputs and I will not endeavor to do so. 

To strike a personal note, my task as Regional Chairman has 
been greatly facilitated by my association with the WHO Program 
for the Prevention of Blindness, first as a staff member and later 
as a periodic short-term consultant. With the I APB and the WHO’s 
programs having a very close congruence, if not identical aims, an 
independent IAPB structure has not been considered entirely 
necessary nor has it been developed in the South-East Asia Region. 

Two major developments need to be highlighted in this report. 
The first concerns the inception of National Committees and the 
formulation of National Programs. Ten out of 11 countries have 
a formal national level established, ranging from a focal point in 
the Ministry of Health as in the Maldives and Mongolia to national 
and state committees as in India. These committees are generally 
multidisciplinary and have government patronage. They include 
NGOs in the field of blindness prevention. Some national commit- 
tees have gone further and developed special task forces or advisory 
committees for specialized facets of the program such as eye health 
education and outreach services. In some countries national pro- 
grams that had been formulated some years ago have been reviewed 
and refined. 

The programs in Nepal and India have had such reviews and 
we expect to hear of the outcome of these quick evaluations from 
the national delegates. In other cases there have been reorientations 
both in the concept and content of the national program. Indonesia 
and Sri Lanka are good examples. Some programs have targeted 
special local problems such as acute angle-closure glaucoma in 
Myanmar and corneal degenerations and glaucoma in Mongolia. 
However, the basic strategy in all of these programs is the delivery 
of eye care as an integral part of primary health care, and nowhere 
is this more explicitly demonstrated than in Thailand and to a lesser 
extent in Bhutan. Whereas manpower training has been a priority 
activity in nearly all national programs, some innovative approaches 
adopted in countries like Bangladesh, Sir Lanka, Nepal, and Thai- 
land deserve special mention. 

The other major development that has been launched somewhat 


82 Plenary Session II— I APB Regional Progress Reports 

belatedly is regionally based training in managerial skill develop- 
ment for ophthalmologists and program managers. Several program 
reviews in the area of health care delivery had indicated that although 
resources were available, program implementation and output fell 
far short of expectations. This was also true of the national preven- 
tion of blindness programs. The major weakness identified as the 
cause of this shortfall was the paucity of managerial skills at all 
levels of the program. 

To meet the requirement for management development, a train- 
ing course was instituted at the Institute of Public Health Ophthal- 
mology in Korat, Thailand, early this year. This course became 
reality through the efforts of Dr. Konyama and the unparalleled 
support given by our Senior Vice President Dr. Akira Nakajima 
and his Center in Juntendo. For the first time it brought together 
participants from two WHO regions in an international faculty. 
Various aspects of community-based training were imparted. Skills 
in epidemiology, planning, health economics, teamwork, leadership 
and other aspects of management were included. This course is likely 
to be the forerunner of similar courses in the future. 

A related development, which was planned for some time, is 
the establishment of an Institute of Community Ophthalmology 
affiliated with the world-renowned Aravind Eye Hospital in 
Madurai, Tamil Nadu, India. At a recent planning meeting under 
the auspices of the Aravind Eye Hospital and Seva Foundation, plans 
were finalized for completing this Institute in 1991. With the open- 
ing of such a facility in the region, the need to train ophthalmologists 
from developing countries in settings approaching their own en- 
vironment will be addressed. This venture should receive generous 
support from all agencies and organizations interested in develop- 
ing and supporting programs for the prevention and control of blind- 
ness in the countries of Africa, Asia, and elsewhere. 

Among the other noteworthy achievements in the region, the 
whole area of manpower and human resource development deserves 
mention. It is perhaps adequate to state at this time that human 
resource development for eye-care delivery has taken various forms 
and processes. Apart from formal, customized courses of study in 
community-oriented eye care and the training of various cadres of 
personnel in subspecialties, there have been site visits in the form 
of study/observation tours to the excellent centers in the region, par- 
ticularly those proficient in community-based services. Examples 
of the salutary effects of such a form of exposure of senior ophthal- 


South-East Asia 83 


mologists and program managers are forthcoming from Sri Lanka, 
Indonesia, and Myanmar. 

Two other aspects of eye care that have relevance to sustainable 
eye care were initiated in the region under the auspices of a project 
supported by the United Nations Development Program (UNDP). 
The establishment of a local production means for eye medication 
was put into action as a part of national programs. This became 
necessary in the context of the spiralling cost of eye medication in 
most countries of the region. This followed an initiative taken by 
the WHO Prevention of Blindness Program with the cooperation 
of Christoffel-Blindenmission (CBM), which has had several years’ 
experience in this field, particularly here in Africa. 

The second innovative endeavor involved the inception of low- 
cost eyeglass production units to provide indigent populations with 
affordable spectacle correction. Such innovations have great poten- 
tial to meet the needs not only of children and young adults with 
refractive errors, but also to make strides in the correction of 
presbyopia for an ever-increasing population of presbyopes. Fur- 
thermore, the needs of the large number of persons who have been 
operated on for cataract but who cannot afford the added costs 
that accrue from the implantation of intraocular lenses can be ad- 
dressed as well. 

Primary eye care has come of age in the South-East Asia Region. 
Almost all national programs have shown that eye care could and 
should be delivered as an integral part of primary health care with 
community-based action and excellent tertiary centers playing a sup- 
portive role in training, research, and specialized service delivery. 
Primary health care has received a significant boost through the 
introduction of cataract surgery at the primary health-care level. 
For this booster effect to be sustainable, however, we must not rely 
solely on numbers. The whole question of quality assurance and 
evaluation of results needs to be addressed. Quality care in pre- 
operative assessment, surgical technique, and postoperative follow- 
up is mandatory. While we speak of Cataract-Free Zones we must 
also ensure that they will be blindness-free zones as well. It would 
be a great human tragedy and a travesty if we leave behind a trail 
of elderly persons who have traded their painless curable blindness 
for painful permanently blind eyes. 

Ladies and gentlemen, in conclusion it is fair to say with humility, 
but with satisfaction, that the countries of the region have led the 
way in tackling the immense burden of needless blindness with 


84 Plenary Session II— I APB Regional Progress Reports 

dedication, innovation, and hard work. Many of those involved in 
this crusade and the non-governmental organizations that supported 
them are here at this Assembly, and I salute them. However, much 
more remains to be done in the wake of increasing target popula- 
tions and in the context of new advances that research and develop- 
ment is making possible. While we strive for excellence in stripping 
preretinal membranes or designing high-technology lasers to sculpt 
the cornea, let us remember that it takes only some dark-green leafy 
vegetables or a little vitamin A in the short term to make the dif- 
ference between light and darkness for hundreds of thousands of 
children. We have a social obligation to do both if sustainable eye 
health for all by the year 2000 is to become a reality. Thank you. 


10 


Regional Progress Report: 
India 1 

Prof. S.R.K. Malik 

PREVENTION AND CONTROL OF 
BLINDNESS IN INDIA: 1986-90 


INTRODUCTION 

Blindness is one of the major health problems in the developing 
countries in Asia, Africa, and Latin America. About 90 percent 
of the world’s blind population is located in these countries. Com- 
pared to prevalence of blindness rates varying between 0.15 percent 
and 0.25 percent in the industrialized countries of Europe and North 
America, the rate is over 1.0 percent in many developing countries. 

Two thirds of the world’s blindness is accounted for by cataract, 
trachoma, xerophthalmia, and onchocerciasis (or river blindness). 
In Asia, over 70 percent of blindness is due to cataract; and 
glaucoma, trachoma, and xerophthalmia are other significant 
causes. 


BLINDNESS IN INDIA 

India has perhaps the largest blind and potentially blind popula- 
tion in the world. Various estimates of the magnitude of visual im- 
pairment and blindness have been made, as a result of surveys at 
different times. The two landmark surveys of 1971-73 and 1986-88 
show that the prevalence of blindness (visual acuity of less than 


ir The unabridged version of this paper, including tables and workshop recom- 
mendations, is available from Dr. Carl Kupfer; National Eye Institute; National 
Institutes of Health; Bldg. 31, Rm. 6A-03; Bethesda, Maryland 20892, USA. 


85 


86 Plenary Session II— I APB Regional Progress Reports 

6/60) has increased during this period from 1.40 to 1.49 percent 
of the population. Blindness is more prevalent in rural areas (1.62 
percent), which constitute over three fourths of the population, than 
it is in urban areas (1.03 percent). 

The changing pattern of the causes of blindness and their relative 
magnitude in India illustrates that cataract has emerged as a more 
predominant cause of blindness, accounting for about 81 percent 
of total blindness in India, as compared with 55 percent two decades 
ago. The prevalence of glaucoma has since become four times as 
great. Refractive error and central corneal opacity have also become 
prominent, calling for urgent corrective action. On the other hand, 
trachoma and vitamin A deficiency now appear less of a problem. 


THE NATIONAL PROGRAM FOR CONTROL OF BLINDNESS 

Recognizing that 85 percent of blindness is either preventable or 
curable through treatment by modern medical or surgical interven- 
tions, a scientifically and comprehensively conceived National Pro- 
gram for Prevention of Visual Impairment and Control of Blind- 
ness, which later was renamed the National Program for Control 
of Blindness (NPCB), was launched by the Government of India 
in 1976. It aimed at reducing the prevalence of blindness from 1.4 
percent to 0.3 percent by the end of the century. The fourfold ap- 
proach of this program was to intensify educational efforts on eye- 
health care; provide immediate relief to people with cataract and 
other eye diseases in far-flung areas through mobile units and eye- 
camps; establish permanent properly equipped eye-care infrastruc- 
tures at various levels, which would include the development of 
ophthalmic and ancillary manpower and fully involve voluntary and 
non-governmental organizations as well as the private sector in eye 
care. 


EYE-CARE SERVICES 

Considerable progress has been made in developing the infrastruc- 
ture of eye-care services. Of the 42,000 eye beds, 4,000 are in mobile 
units, 3,800 in district hospitals, 11,500 in eye hospitals, 6,200 in 
medical colleges, 2,000 in regional eye institutes and at the Dr. 
Rajendra Prasad Centre for Ophthalmic Sciences in New Delhi, and 
14,500 in private nursing homes and with private practitioners. 


India 87 


Besides, beds in public health care facilities in a number of states 
are used for eye patients, whenever eye camps are organized there. 


MANPOWER AND TRAINING 

For ophthalmic manpower development, degree and diploma courses 
for postgraduate work in ophthalmology are available in 100 medical 
colleges, regional and national eye institutes, and in some post- 
graduate institutes in the voluntary sector. In all, they train between 
275 and 300 postgraduates per year. For training of ophthalmic 
assistants, 37 training centers have been established. 


CATARACT SURGERY 

About 60-65 percent of cataract operations in India are performed 
by voluntary societies and non-governmental organization all over 
the country, largely through the eye camp approach. Whereas the 
total performance of over 9.5 million during 1981-90 appears credit- 
able, the annual performance has touched a plateau of less than 
1.2 million, in spite of augmentation of the infrastructure. Among 
the reasons diagnosed for this levelling off are: 

1. Underutilization of existing facilities either because of in- 
adequacy of trained personnel or funds. 

2. Underutilization of available ophthalmic manpower for com- 
munity cataract surgery. 

3. Increasing switch-over to cataract surgery with IOL. 

4. Socioeconomic barriers among people in rural areas, in- 
cluding nonavailability of family members to accompany 
them; extreme poverty causing inability to travel to eye camps; 
and the belief, particularly in the north of India, that eye 
operations should be avoided during the summer months and 
the rainy season. 


CURRENT MAGNITUDE OF THE CATARACT BACKLOG 

The recent NPCB-WHO survey has revealed that about 81 percent 
of the blindness in India is due to cataract. Supplemented by another 
recent cataract prevalence study, the tentative conclusion is that, 


88 Plenary Session II— I APB Regional Progress Reports 


based on a population of 800 million, there are currently 22.26 
million operable cataract eyes (visual acuity of less than 6/60) of 
which 8.42 million are mature or hypermature cataracts that need 
to be operated urgently. There are 52 million immature cataracts 
and another 18 million incipient cataracts. The problem is likely 
to become more acute in the coming years because of the change 
in the demographic pattern: there will be a greater percentage of 
persons in the over-40 age group — those who naturally have a higher 
cataract potential. Dealing with these problems will require a massive 
increase ir cataract surgeries to roughly 4 million or more operations 
per year, as compared with the present annual level of 1 .2 million. 


PROPOSED REMEDY FOR TACKLING THE BACKLOG 

The remedy lies partly in: 1) making optimal use of the existing 
ophthalmic manpower and hospital facilities through incentives and 
use of management strategies; 2) encouraging new and innovative 
approaches; and 3) establishing a large number of base eye hospitals 
all over the country, particularly at the subdivisional level. 

At present, out of 6,500 ophthalmologists in India, only one 
third are actively involved in providing community cataract surgery. 
Many more need to be oriented and trained for this purpose and 
immersed in it by various approaches, including incentives. 


NEW APPROACHES FOR ACHIEVING 
HIGHER CATARACT OPERATIONS: 

Optimizing Utilization of Eye Hospital Infrastructure 
During Lean Months 

In Northern India, without any sound scientific basis, summers and 
rainy seasons have traditionally been lean months for cataract 
surgery. Consequently, hospital facilities have remained greatly 
underutilized during these months. To correct this, an experimen- 
tal operational research project has been taken up jointly by the 
National Society for the Prevention of Blindness (NSPB) — India, 
Sight Savers (Royal Commonwealth Society for the Blind), and 
Multanimal Modi Charitable Trust (at Modinagar Eye Hospital since 
April 1990). 

With this hospital as the base, eye-health educational activities 


India 89 


for molding public opinion and dispelling doubts and fears about 
eye surgery during the months of April through October 1990 were 
taken up in the hinterland near this hospital with the help of local 
voluntary organizations. Screening camps were held at specified 
places in the catchment area. Identified cataract cases were brought 
to the base hospital at Modinagar for free surgery and transporta- 
tion back home. The hospital wards were air-cooled to make the 
patients more comfortable. 

As a result, the output during April-September 1990 was 1214 
cataract surgeries as compared to an average of 355 surgeries dur- 
ing the same months in the three preceding years (1987-89). In fact, 
not only were the existing facilities fully utilized but more beds had 
to be added to meet the additional demand. During one of these 
six months, full motivational work could not be done due to un- 
settled political conditions. Otherwise, the performance would have 
been even better. The awareness created through the motivational 
campaign has led many more patients to come directly to the hospital 
and the tempo has been sustained even after the lean period. Dur- 
ing October 1990, the number of surgeries was 291 as compared 
to an average of 143 surgeries during October 1987-89. 


BASE HOSPITAL APPROACH 

The approach of having the base eye hospital function at an op- 
timal level of available facilities, including eye beds, through the 
process of creating demand, organizing screening camps in the catch- 
ment area, and transporting the diagnosed cataract cases to the base 
hospital is less costly and organizationally less hazardous than 
organizing eye-care camps. This approach is in keeping with the 
basic objectives of NPCB and is being successfully tried out by a 
number of voluntary organizations working in the field of eye care. 


CATARACT-FREE ZONE 

Another innovative approach has been experimentally tried with 
considerable success by NSPB in Datia District (population 372,000) 
of Madhya Pradesh in collaboration with the District Collectors 
and the Chief Medical Officer (CMO) to make it a cataract-free 
zone for the time being. This consisted of screening the entire 
population in the age-group of 40 years and above (about 67,000 


90 Plenary Session II— I APB Regional Progress Reports 

persons). This was done with the help of district paramedical and 
revenue staff, who helped locate blind persons (with visual acuity 
of less than 6/60) and, aided by ophthalmic teams, identified those 
suffering from cataract. Eye camps were organized in which 84 per- 
cent of all identified cataract cases were operated upon. 

This experiment, which took only six months, was made pos- 
sible by the personal involvement and dedicated leadership provided 
by the collectors, Mr. Pravesh Sharma and his successor Mrs. Amita 
Sharma. This experiment has shown that motivated district collec- 
tors can provide the requisite leadership in collaboration with 
dedicated voluntary organizations working in the field of eye-health 
care to make a given area cataract-free within a specified span of 
time. In this way, the cataract backlog has been reduced to a 
manageable limit that can be taken care of by the existing infrastruc- 
ture. Encouraged by this experiment, NSPB has requested the 
Government of India to select districts in the country where 
collectors will be given responsibility to make them cataract-free. 
Some districts, particularly in Tamil Nadu and Himachal Pradesh, 
have already started work in this direction. 


EYE BANKING 

Although at present there is an estimated backlog of 365,000 cor- 
neal grafting cases in India, only about 3,000 operations are 
performed annually. The annual availability of donor tissues is at 
present about 7,000 eyes as compared to 3,000 some four or five 
years ago. 

This increased availability is due to the vigorous efforts made 
to create awareness of eye donations, particularly by the Times Eye 
Research Foundation (TERF) as a result of which 215,000 pledges 
for eye donations have been received. The total number of pledges 
at present is 325,000 lakhs. Increases in the number of eye banks 
from 45 in 1983 to 146 in 1990 has also improved availability. 
Although not all of them are of the requisite standards of surgical 
care or efficiency, some render good service. The eye bank run by 
the Indian Red Cross Society, Dholka Branch in the Ahmedabad 
District of Gujarat under the stewardship of Mr. Gautam C. Maz- 
mudar with the help of its 53 rural eye collection centers provides 
over one fourth of the total eyes collected in India. This Society 
with the help of NSPB is experimenting with new approaches for 


India 91 


getting cadaver eyes. However, most other eye banks need to be 
helped to become equally efficient. Many districts in the country 
are without any eye bank or eye collection centers. The Govern- 
ment of India is planning to expand eye -banking facilities and set 
up at least one eye collection center in each district, establish eye 
banks in all of the remaining medical colleges where they do not 
exist at present, and also involve organizations in the voluntary 
sector. 


VITAMIN A PROPHYLAXIS 

The program of vitamin A prophylaxis for children has been carried 
on all over India since 1971, as a part of the Maternal and Child 
Health (MCH) Program of the Department of Family Welfare. Its 
coverage through the MCH network presently extends to about 60 
percent of the eligible children. The recent survey shows that 
prevalence of nutritional blindness due to Vitamin A deficiency has 
come down to 0.04 percent as compared with 2.00 percent two 
decades ago. But doubts have been raised in many quarters about 
the degree of reduction projected by the recent survey— a situation 
that would warrant further detailed surveys. 


REFRACTIVE ERRORS 

Visual impairment due to refractive errors in children has assumed 
special prominence. This problem is being combated by intensify- 
ing eye screening of children by NPCB’s mobile units and various 
voluntary organizations, particularly NSPB functioning centrally 
and through its state and district branches. An innovation introduced 
involves rural school teachers in the screening program. The West 
Bengal branch of NSPB has so far involved 2,114 rural teachers in 
1,313 schools covering 1,717 villages in the rural areas of the State, 
reaching about 283,000 children. About 13-14 percent of the children 
are found to suffer from ocular ailments and are referred to the 
nearest eye clinic for further ophthalmic advice and treatment. In 
the Jalgaon District of Maharashtra, eye screening of all school- 
children has been completed by involving schoolteachers with the 
help of the Zila Parishad District administration. These innovations 
are proposed to be replicated in other parts of the country. 


92 Plenary Session II— I APB Regional Progress Reports 

EYE-HEALTH EDUCATION 

Under NPCB, intensification of educational efforts on eye-health 
care is a priority step in the action plan. This calls for involving 
all available mass media, both electronic and others, and optimiz- 
ing the use of the existing extension education network— and even 
extending it. 

A lot of work is being done in this field both at the central and 
state government levels as well as by NSPB in the voluntary sector. 
Eye-health education materials in the form of posters, charts, 
folders, and booklets have been produced by the central and some 
state health education bureaus and by NSPB and have been widely 
distributed and exhibited. NSPB brought out a report on the “Safe 
Approach to Eye Camp Surgery” as a result of the national seminar 
which it organized after some mishaps at eye camps came to its 
notice. The guidelines that were developed have been widely 
distributed. 

During the last four years, NSPB has taken up intensive eye 
health education program. Some of the salient components are as 
follows: 


1. Public Lecture Series 

In collaboration with UNICEF, a series of popular public 
lectures were organized covering topics such as nutritional 
blindness, eye injuries, glaucoma, squint, contact lenses, 
diabetes and the eye, and cataract surgery and IOL implants. 
The second series of public lectures on pediatric 
ophthalmology is being organized, again in collaboration 
with UNICEF. 

2. Poster and Essay Competitions 

Such competitions on various themes of eye care, preven- 
tion of blindness, and public interest and participation in 
improving the health of the nation have been annually 
organized for schoolchildren and others. The winning poster 
entries have been included in the Society’s poster series for 
wide distribution. 

3. Prevention of Blindness Week 

Every year NSPB and its branches observe Prevention of 
Blindness Week in early April in which a subject of public 
health importance relating to eye care is chosen as the theme. 
National focus is given to the theme by extensive coverage 


India 93 


through television and radio networks, newspapers, public 
lectures, display of banners, hoardings, and wide distribu- 
tion of publicity material on the topic. State health depart- 
ments also participate in observance of this week. During 
the last four years, the topics covered have included 
glaucoma, industrial blindness, prevention of eye injuries, 
and prevention of blindness in children. 

4. National Fortnight on Eye Donations 

This fortnight is observed by NSPB and its various branches 
along with the Times Eye Research Foundation (TERF) to 
create awareness of the problem of corneal opacity and the 
importance of eye donations. 

5. Press Releases and Features 

Press releases and features are periodically issued on various 
eye-related topics, e.g. hazards to eye health by crackers, 
colored water balloons, bows and arrows, and colored 
powder, particularly during the holidays of Holi, Diwali, 
and Dussehra. 

6. Special Campaign on Glaucoma 

In collaboration with NPCB, a special educational campaign 
on glaucoma was mounted relating to the increased 
prevalence of this blinding disease and the need for timely 
check-ups. Two colored posters and two folders entitled 
“Glaucoma— A Lurking Thief” and “Glaucoma— A Blind- 
ing Disease” were produced and widely distributed through 
State Health Departments. 

7. Special Advertisement Campaign 

A special campaign for public education on various eye- 
health topics was organized by advertisements through na- 
tional and regional newspapers and periodicals all over 
India. The messages were in layman’s language on topics 
such as “Your child’s eyes — Mothers, do you know?”; “Is 
your child squinting?”; “Do not ignore conjunctivitis”; 
“Glaucoma — a blinding disease”; and “Diabetics, beware!”. 
More topics are being addressed in a similar advertisement 
campaign that will constitute the second stage. 

8. Quarterly Journal “Hamari Aankhen” 

The Society publishes a quarterly journal called “Hamari 


94 Plenary Session II— I APB Regional Progress Reports 

Aankhen,” which contains useful information and articles 
on eye-health care for wide distribution. 

9. Some Innovative Projects 

Some of the branches of the Society have launched in- 
novative projects such as providing eye screening for vehicle 
drivers and operators of heavy-duty equipment, develop- 
ing a home eye-testing chart, and involving rural school- 
teachers in eye screening of children. 

10. Resource Center Set Up 

A resource center for eye-health educational material has 
been set up by the Society whereby all printed, audio, and 
video materials on eye-health care are being collected from 
different organizations from both within the country and 
abroad. A large treasury of such materials has already been 
received and is being stored for necessary documentation 
for use as reference and resource materials and for produc- 
tion of educational material on eye health care. 

11. Workshop for Media Persons 

To remedy the existing gap of inadequate in-depth exposure 
of media persons to various aspects of blindness, including 
its magnitude; causes; prevention, cure, and rehabilitation; 
social and economic aspects; as well as what is being done 
to solve the problems in this field and what more is needed, 
NSPB organized a workshop in collaboration with WHO 
and the Ministry of Health. Media personnel were drawn 
from both print and electronic media. This three-day 
workshop, which was the first of its kind to be organized 
by an NGO in India, was attended by 25 senior media per- 
sons and 29 health administrators, health educators, social 
scientists, and ophthalmologists. It created better under- 
standing and appreciation of the problems connected with 
blindness and resulted in more coverage of both news and 
features related to blindness. 


As a result of recommendations by the Central Coordination 
Committee of NPCB, two or three lectures from this program have 
been included in the course for Indian Administrative Service pro- 
bationers at the National Academy of Administration in Mussouri 


India 95 


with a view to making these administrators aware of possible blind- 
ness problems in their districts. 

The States have been asked to establish District Blindness Con- 
trol Societies which will function under the District Collectors for 
implementation of NPCB by involving the voluntary organizations 
of the area. These societies will also be able to raise funds from 
local sources for monitoring the program. 


REVIEW OF PROGRAM IMPLEMENTATION 

The implementation of this program was reviewed by two national 
workshops organized by the Ministry of Health and Family Welfare 
and NSPB respectively during the first quarter of 1989. NSPB’s 
three-day workshop, which was attended by over 70 participants, 
including senior ophthalmologists, health administrators, social 
scientists, and representatives of voluntary and non-governmental 
organizations and international agencies, made an in-depth appraisal 
of the impact of various program components on control of blind- 
ness and made important recommendations for more effective im- 
plementation and progress. These recommendations received con- 
siderable attention at the highest government quarters and also of 
the Planning Commission. Important recommendations of the two 
workshops are available (see footnote on page 85). 


INTERNATIONAL INTEREST AND PARTICIPATION 

The program has evoked keen interest, involvement, and support 
of international organizations and agencies. WHO, DANIDA, Sight 
Savers, Christoffel-Blindenmission, Helen Keller International, Seva 
Foundation, Operation Eyesight Universal, and other international 
agencies have provided generous help for specific activities under 
the program or to voluntary organizations working in the field of 
prevention of blindness. DANIDA’s assistance in Phase I has con- 
siderably helped the program in establishing the infrastructure, 
mobile units, and training. 

In phase II it will assist in the field of equipment and transport, 
pilot district projects, training activities, and monitoring systems. 
About 25 percent of the cataract surgeries done by voluntary 
organizations have been financed largely by Sight Savers and 
Christoffel-Blindenmission. The former has been particularly 


96 Plenary Session II— I APB Regional Progress Reports 

helpful in funding the construction of small rural eye hospitals, 
child-development service projects, and in providing eye-care 
facilities to victims of the Bhopal gas tragedy. 


CONCLUSION 

During the last four years, the Government of India’s commitment 
to and the community involvement in this national program have 
continued unabated. In fact, this program has witnessed great 
cooperation and coordination between government on the one hand 
and voluntary, non-governmental, and international agencies on the 
other. The recent NPCB-WHO survey has, however, shown that the 
country has a long way to go, particularly in treating the cataract 
backlog, to reach the avowed goal of reducing blindness prevalence 
to three per thousand in the general population. 

The successful and innovative approaches mentioned earlier 
must be made a regular part of the program. More financial and 
other resources must be made available for extensive eye-health 
education activities. Eye-banking projects must have fuller involve- 
ment of the voluntary NGOs. In tackling the cataract backlog there 
should be increased stress on total eye care with greater attention 
to glaucoma, refractive error, and corneal blindness. There should 
be regular monitoring and evaluation of the program and greater 
use of management approaches. The program should not be allowed 
to wither because of a lack of adequate resources. Finally, greater 
community participation and financial support — both national and 
international — must be forthcoming for this noble cause. 


11 


Regional Progress Report: India, 
Bangladesh, Pakistan, and Sri Lanka 

Dr. Rajendra Vyas 

At the beginning of this century, some 90 years ago, blindness in 
the 11 countries of the South-East Asia Region was rampant. Over 
the last nine decades and especially since the Second World War, 
because of the progress in ophthalmology and development of better 
techniques, cataract — the giant among the causes of blindness in 
this part of the world — has been the focus of attention. After 
cataract the major causes of blindness in this part of the world are 
refractive errors, glaucoma, and central corneal scars. 

In Bangladesh, India, and Sri Lanka, efforts made by govern- 
mental agencies and NGOs at both national and international levels 
have helped make the public aware that cataract blindness can be 
cured. What is alarming is that cataract blindness on the Indian 
sub-continent is expanding, possibly because of the increasing life 
span. It is said that in India alone the prevalence rate of blindness 
in both eyes has increased from 1.40 percent to 1.51 percent, accord- 
ing to a NPCB-WHO survey. Applying this criteria to the popula- 
tion projection of 1989, the number of cataract-blind in both eyes 
in India will be 13.21 million. According to a survey by Drs. Darwin 
Minassian and Vijay Mehra, the number of persons becoming 
cataract-blind in both eyes is 3.80 million per year. 


INDIA 

Among the 11 countries in the region, perhaps the greatest strides 
in eliminating cataract blindness have been taken in India with the 
help of national programs for control of blindness and funding from 
international non-governmental organizations. This effort began 
with just 50 eye camps in 1970 and today, after 20 years, the number 
of eye camps conducted annually is as high as 2,500. Over the last 


97 


98 Plenary Session II— I APB Regional Progress Reports 

20 years, the sight of 2 million people has been restored and over 
20 million have been treated for various eye ailments. Following 
in the footsteps of Sight Savers, which initiated its action against 
blindness in 1970, the Government of India formulated its National 
Program for control of blindness and visual impairment in 1975. 
Training courses for ophthalmologists, paramedics, and ophthalmic 
assistants, plus the use of mobile ophthalmic vans and the upgrading 
of all district hospitals have formed an essential ingredient of the 
national program for control of blindness and visual impairment. 

BANGLEDESH AND PAKISTAN 

Eighteen years ago, when Bangladesh became independent, it had 
two ophthalmic hospitals in the voluntary sector and a few oph- 
thalmic beds attached to medical colleges in Dhaka and Chittagong. 
I was privileged to initiate prevention of blindness activities in 
Bangladesh on behalf of Sight Savers 17 years ago and today 
Bangladesh has several eye hospitals and a large number of trained 
ophthalmologists and mobile ophthalmic vans. In the beginning 
stages, these ophthalmologists were trained in India and Singapore, 
and later training was begun in Bangladesh. Pakistan too had been 
suffering from lack of trained personnel and adequate ophthalmic 
facilities. With the intervention of Sight Savers and the state, con- 
siderable interest has been stimulated; and in Sind, Baluchistan, and 
Punjab, a limited number of well-equipped ophthalmic centers have 
been established to help the poor. 

SRI LANKA 

Sri Lanka began its national prevention of blindness program in 
1970-71 with the establishment of a mobile ophthalmic unit. The 
assistance of Sight Savers was particularly important at the outset. 
However, local organizations subsequently began to show keen in- 
terest and a low-vision aid center was established. Unfortunately, 
because of recent unstable conditions, the progress in Sri Lanka 
has been thwarted. We hope that conditions will soon improve, so 
that work can be expanded. 

CONCLUSION 

Four years ago when the last IAPB General Assembly was convened 


India , Bangladesh , Pakistan , and Sri Lanka 99 

in India, the picture was darker. There was a paucity of trained per- 
sonnel, inadequacy of financial resources and unwillingness of 
ophthalmologists to operate in rural areas. To some extent, these 
factors have decreased. However, it would be hoping against hope 
to say that all cases of preventable or curable blindness will come 
under the purview of community ophthalmology by the end of this 
century. A Herculean effort will have to be made especially by the 
NGOs at national and international levels to create awareness, both 
within the masses and within those in power, to prevent or cure 
avoidable blindness. 



12 


Regional Progress Report: 

Western Pacific 

Dr Frank Billson, Dr Kazuichi Konyama, and Dr Lim Kuang Hui 

WESTERN PACIFIC REGION 

The problem of blindness in the Western Pacific Region is similar 
to the rest of Asia, although it is generally of less severity in the 
majority of these countries. Much of the blindness in the region 
is preventable and curable by application of known technology. 

The great diversity in socioeconomic development within the 
countries of this region reflects their problems relating to blind- 
ness. The situation is further compounded by geography and climate 
as well as socioeconomic and cultural background. 

The emphasis of WHO collaboration has been on the develop- 
ment of national prevention of blindness programs that focus on 
essential eye care especially in underserved areas. In the developing 
countries in the region the overall blindness rate varies between 0.2 
percent in Korea and 1.0 percent in countries like Laos, Vietnam, 
and the Philippines. The main causes of blindness in this region 
are cataract, injuries, malnutrition, trachoma, and infections. 
Available data illustrate that countries in the region fall into three 
distinct groups: 

1. Those that have active national programs or are able to act 
as the resource such as Australia, Japan, New Zealand, and 
Singapore; 

2. Those that have initiated national programs like China, Viet- 
nam, and Laos; and 

3. Those that have programs being implemented within their 
countries like Malaysia, the Philippines, and the South Pacific 
Islands (Oceania). 


101 


102 Plenary Session II— I APB Regional Progress Reports 

SOUTHERN SUBREGION 

The southern part of the Western Pacific (Oceania and New Zealand) 
prevention of blindness activities pose special problems with 30 
countries and territories occupying 20 to 30 thousand islands in- 
habited by a total of 10 million people. Many islands have fewer 
than 100 people, and many islands have none at all. Since the 1960s, 
island groups have demanded and been given the freedom to govern 
themselves. Fiji and Papua New Guinea are the largest developing 
nations in this region; and Australia and New Zealand are in- 
dustrialized countries with the resources and the will to assist. 

Fiji and Papua New Guinea have medical schools, and we can 
anticipate the training of ophthalmologists and eye-health workers 
in both the University of the South Pacific (in Fiji) and in the Univer- 
sity of Papua New Guinea. Over 70 percent of the doctors in the 
South Pacific were trained in the Fiji Schools of Medicine. Conse- 
quently, there is a tradition of training in the region. Both Fiji and 
Papua New Guinea are developing national primary eye-care 
programs. 

Regional blindness rates range between 0.2 percent in Australia 
and 1.0 percent in countries like Papua New Guinea, however much 
of the cataract blindness is being addressed by teams of Australian 
Eye Doctors organized through ASPECT (Australian South Pacific 
Eye-Care Team) with funding from the Australian Government’s 
aid program, the Australian International Development Assistance 
Bureau. Some countries such as the Solomons have sought to have 
the service of a full-time ophthalmologist with assistance from non- 
governmental organizations such as Sight Savers and Foresight. In 
addition, Australia has assisted in the training of an ophthalmologist 
from Tonga. 

Partnerships of international NGOs, including Sight Savers, 
Helen Keller International, and Christoffel-Blindenmission have col- 
laborated with South Pacific Islands in developing prevention of 
blindness programs in association with the South Pacific Council 
for Blind Persons and Blindness Prevention. 


PAPUA NEW GUINEA 

The Australian government, which has continued to have strong 
links with Papua New Guinea, is committed to respond to requests 
for development in Papua New Guinea in the area of blindness and 


Western Pacific 103 


its prevention. International non-governmental organizations 
such as Sight Savers (Royal Commonwealth Society for the 
Blind), Foresight, Helen Keller International, and Christoffel- 
Blindenmission have assisted. Recently the Papua New Guinea 
government appointed a national director of its prevention of blind- 
ness program. The implementation of the program, which is centered 
on primary eye care, is about to commence. The primary eye-care 
program will also include a health extension officer and a nursing 
orderly. However, such a comprehensive program faces difficulties 
in a country with 3 million people and 800 languages and where 
mountainous terrain makes transportation links impossible and air 
links imperative. In Papua New Guinea there is a shortage of eye 
doctors, as there is in the Pacific public sector in general, with 
rewards being higher in the private sectors. Nevertheless, the work 
force for eye care is increasing. 

Because the proximity of Australia to Papua New Guinea makes 
close cooperation in prevention of blindness activities logical, there 
is already collaboration in training eye doctors. 


SOLOMON ISLANDS 

An ophthalmologist financed by Sight Savers is working full-time 
in the South Pacific and has played an important role in assisting 
primary eye-care services. In addition, he has worked with a 
Solomon Islands ophthalmologist who had also received training 
in Australia. 


TONGA 

A WHO scholarship and assistance from Foresight have helped train 
a Tongan ophthalmologist in Australia. This ophthalmologist has 
already carried out a survey of blindness and has formulated a 
national prevention of blindness program. 

Vanuatu, Kiribati, Tonga, Tuvalu, the Cook Islands, and the 
Solomons are island nations that are good examples of the prob- 
lems of development of eye-care services and prevention of blind- 
ness activities in the South Pacific. Because of the relatively low 
population, the number of necessary cataract surgeries can be en- 
compassed by the visiting team of foreign surgeons. However, 
because these countries desire and need to develop their own 


104 Plenary Session II— I APB Regional Progress Reports 

in-country eye-care services, it is necessary to initiate in-country 
surgical services and in-country eye-care education where possible. 

Since 1984 the Australian South Pacific eye-care team has visited 
the above nations and has provided surgical services. In addition, 
a training component has been introduced. The program in the 
Solomons was discontinued in 1985. However, Tonga in 1986 and 
the Cook Islands in 1989 have received surgical services with a train- 
ing component. 

Annual visits are made to the following countries: Vanuatu, 
Kiribati (two teams visit; the first provides outpatient and teaching 
services, the second performs surgery and undertakes the surgical 
training of a Kiribati doctor), Tonga, Tuvalu (biennially because 
of the small population), and the Cook Islands (also visited 
biennially). 

The training of personnel to perform eye surgery continues to 
progress satisfactorily in Vanuatu and Kiribati, the two most 
populous countries visited by the eye-care team. The small volume 
of surgery in Tuvalu would make it difficult for a surgeon to main- 
tain his skill. 

In 1989 this team carried out a population-based survey of eye 
disease in the Pacific, providing data on the prevalence of blind- 
ness in Melanesia. Another survey has been conducted in Tonga 
and has provided data for Polynesia. The repetition of these surveys 
at regular intervals will provide a method of determining the effec- 
tiveness of surgical interventions and of the eye surgeons who are 
being trained in-country. 


AUSTRALIA 

Foresight is an Australian international aid and prevention of blind- 
ness agency seeking to complement existing eye-care services. In the 
South Pacific it is committed to work with other NGOs in the region, 
including Sight Savers, Christoffel-Blindenmission, and Helen Keller 
International. 


NEW ZEALAND 

New Zealand, as part of Oceania, also has been a resource in the 
area and has assisted training and development in the Cook Islands 


Western Pacific 105 

and Fiji. The possibilities of collaboration with Australia should 
be gradually developed. 


CHINA 

The blindness survey carried out in the period 1984 to 1986 in many 
parts of China, revealed that the overall blindness rate ranges from 
0.14 percent in Guangdong to 0.67 percent in Fijiang; the average 
is about 0.50 percent. Trachoma, believed for a long time to be the 
major cause of blindness in China, has declined and now cataract 
has become the center of concern. This blindness survey took place 
mostly in rather well-serviced areas. Although the overall situation 
within the underserved areas is unknown, the blindness rate may 
well be higher and include trachoma. 

The vastness of China makes it difficult to estimate the total 
number of unoperated cataract cases. In addition, the survey did 
not study underserved or remote areas. Therefore, the number of 
unoperated cataracts could be as high as 3 million. 

The Beijing Institute of Ophthalmology, Dong Ren Hospital, 
in Beijing, which accommodates the National Board of Blindness 
Prevention, has recently been nominated as a WHO Collaborating 
Center. The Chinese national programs were formulated in 1986 
and more than 20 provinces identified their own pilot counties to 
launch primary eye-care development projects. One of the goals of 
these programs is to develop mass-intervention projects for cataracts 
in the final stage of development. 

Because trachoma programs have long been in operation in some 
parts of the country, remarkable results in reducing trachoma and 
also cataract blindness have been achieved in these specific areas. 
The Chinese Ministry of Health rewards such counties with the 
honor of being “A Prevention of Blindness Advanced County.” So 
far there are more than 10 of these counties now in existence. Prov- 
inces well known for their successful programs of primary health 
care are: Heilongjiang, Shanzxij, and Zhojiang. 

The above counties must have met the following criteria: blind- 
ness data are available through population-based surveys, eyesight 
is being restored in more than 70 percent of the cases of curable 
blindness, and there are networks linking all eye-care facilities. 

In China most concern regarding cataract blindness is on the 
currently low surgical output. At the start of the national program 


106 Plenary Session II— I APB Regional Progress Reports 


there were only 50,000 operations per year. The Ministry of Health 
therefore instructed the eye sector to exert every effort to institute 
a rapid increase in cataract extractions. The goal of 500,000 cataract 
operations was to be achieved within five years of 1987. 

In addition, new programs for the care of the disabled and for 
the training of ophthalmologists have been given high priority, and 
better managerial capacity is often the center of annual workshops 
held at various levels. In China primary eye-care development is 
the core of blindness prevention activities. The national experiences 
of success in primary health care creates a favorable environment 
for prevention of blindness activities. Human resources seem ade- 
quate and the commitment of the government is consistent with 
the development of national programs. This commitment, coupled 
with the spirit of self-determination and involvement from overseas 
in finance and technology, should ensure that progress is accelerated. 


KOREA 

At the start of the national program, Korea’s remarkable progress 
in socioeconomic status demanded a different type of action in 
blindness prevention. More weight was given to promote better eye 
health for certain groups of the population. As a result of major 
action elements identified in 1984, the following have been identified: 

1. Primary eye-care services for the rural population; 

2. School eye-health programs for schoolchildren; 

3. Eye-care elements in maternity and child health during early 
life; 

4. Eye health in the workplace and environmental health; and 

5. Eye-care services for the elderly. 

Presently there are more than 700 well-trained ophthalmologists 
taking care of a population of 42 million. The 1988 statistics showed 
that the newly introduced health insurance scheme had covered 95 
percent of the total population. It resulted in 45,000 cataract opera- 
tions completed under insurance. The country, therefore, is already 
equipped with sufficient capacity regarding cataract surgery for the 
whole population and now faces new challenges from blinding 
posterior segment disorders. The future of the national program 


Western Pacific 107 

may proceed to the direction becoming part of the scheme on non- 
communicable diseases control. 


VIETNAM 

National programs in this country give very promising signs. Strong 
activities are being extended in all 22 provinces in the north, as well 
as 13 out of 20 in the south including Ho Chi Minh City. This suc- 
cess has come to be in part because of effective organization with 
the Institute of Ophthalmology in Hanoi and the Dien Bein Phu 
Eye Hospital in Ho Chi Minh City playing leading roles. These 
hospitals link all operational-level prevention of blindness stations 
at provincial, district, and commune levels and keep activities on 
going. Health manpower and administration of the health in- 
frastructure are rather well developed in this country. 

The blindness rate of the country is known to be 0.8 percent 
of which the cataract backlog is estimated to exceed 300,000. Pro- 
vincial operations aim at bringing communes to develop enough 
capacity for detecting cataract cases. Mobile teams are then sent 
from the stations down to the communes. Human resources seem 
to be sufficient and possess enough technology. Great shortages of 
supplies and equipment prevent the rapid increase of output poten- 
tial. However the cataract intervention program, which uses the 
primary health-care approach, is proving to be very workable in 
this country. Blindness from malnutrition is now covered by a new 
program of mass distribution of Vitamin A preparations. Ten pilot 
provinces have just be identified and the program is now being im- 
plemented. Vietnam is actually one of the models for this region 
and thanks WHO and Christoffel-Blindenmission for their consis- 
tent support of their programs. 


LAOS 

National programs are now steadily in progress in the five targeted 
provinces along the Mekong River. The development of the eye- 
health system started from zero when the national programs began 
in 1986 with emphasis on manpower development and establishing 
eye-care networks. The five provinces now have tertiary centers linked 
with pilot districts that are served by trained eye staff. 

Following WHO initiatives the Japanese Government is com- 


108 Plenary Session II— I APB Regional Progress Reports 

mitted to helping develop eye-care systems in Vientiane and 
Louangphrabang. In several provinces cataract programs are now 
taking place. In addition, Thailand has extended technical coopera- 
tion in various ways, and training opportunities are open to all levels 
of eye personnel with many options available for selection of courses. 


PHILIPPINES 

In 1989 WHO helped the Ministry of Health outlined a National 
Model for the Prevention of Blindness. Emphasis was made to 
mobilize resources in the private sector, including all professional 
groups of ophthalmologists in the country under central coordina- 
tion. A clear objective has been placed on the early solution of the 
cataract problem, which is estimated to be over 1 million. 

Mass distribution of Vitamin A was revived in 1989 under a new 
nutrition program at the Institute of Nutrition. Regarding eye care, 
there is a great need for rehabilitation eye units at provincial 
hospitals. Manpower development needs to be accelerated for the 
area. To that end the eye sector needs to move further utilizing the 
principles of primary health care. 


SINGAPORE 

Singapore has been fortunate in this regard. A small country (570 
square kilometers) with a small population of 2.6 million residents 
and virtually no rural blindness, the present rate of less than 50 
blind per 100,000 population (0.05 percent) is amongst the lowest 
in countries where blindness is reported. Registration of blindness 
is not required by law, and even allowing for under-registration, the 
figures are still low. There are a number of reasons for this. Apart 
from being a small nation with an absence of a rural community, 
Singapore has enjoyed a rapid industrial and economic growth in 
the past four decades. The gross national product (GNP) has risen 
tenfold from $2,189 million in 1960 to $22,846 million and per capita 
GNP has increased from $1,329 to $11,100 over the same time period. 

The pattern of blindness in Singapore has changed considerably 
over the past 30 years. Keratomalacia, corneal ulceration and 
ophthalmia neonatorum, which were common in the 1950s, were 
replaced in the 1960s by glaucoma, optic atrophy, and corneal 
disease. In the 1970s congenital and developmental causes of blind- 


Western Pacific 109 


ness emerged with retinal disease and diabetic retinopathy. In the 
1980s the five most common causes of blindness were: 


Retinal Disease 29.4% 

(diabetic and vitreo-retinal degeneration) 

Congenital and Developmental 20.9% 

Glaucoma 15.9% 

Optic Atrophy 12.8% 

Corneal Disease 6.3% 


With the rise in affluence, Singapore is also seeing more 
monocular blindness from trauma, mostly related to industry and 
road accidents. 

The efficient administrative infrastructure and political stabil- 
ity of this island-nation has allowed development of medical ser- 
vices at all levels both in the public and private sectors. Singapore 
is fast becoming a center for service within the region, not only 
for patients but also for presentation of health -related courses and 
conferences. 

In 1990, the government targeted the development of ophthal- 
mology for rapid promotion and inaugurated the Singapore Na- 
tional Eye Center. This was in keeping with Singapore’s striving for 
excellence and emphasizing itself as a global nation. Also in 1990 
the government launched the Singapore Vision-Care Program, to 
foster preventative eye care through mobile eye screening and public 
education, with the primary objective of detecting and controlling 
myopia, industrial vision problems, and blinding diseases of the 
aged. 


MALAYSIA 

In Malaysia, there is also no legal requirement to register the blind. 
However, the Malaysian Ministry of Welfare Services, which main- 
tains a register of disabled persons, showed that as of March 1989, 
there were 100,000 registered blind in this country of 17 million 
people, giving a blindness rate of 295 per 100,000 (0.3 percent). 
Figures from the major government hospital in Kuala Lumpur, the 
nation’s capital city, showed that the common causes of blindness 
were: cataract, trauma, infection, glaucoma, and uveitis. 

In keeping with the Malaysian government’s stress on rural 


110 Plenary Session II— I APB Regional Progress Reports 

development, a prevention of blindness committee of the Malaysia 
Association for the Blind, with representatives from the relevant 
government ministries has promoted annual campaigns and mobile 
eye screening in rural areas. The committee also set up the Tun Hus- 
sein Onn Eye Hospital in Kuala Lumpur in March 1986. The latest 
annual report of the hospital showed a high level of performance 
targeted toward prevention of blindness by service- and teaching- 
orientated activities. 

The country is now prepared for the start of national programs 
for the peninsular part of the country. Because rehabilitation has 
long been very strong in this country, this element seems to have 
special emphasis. Whereas Sabah and Sarawak need more 
strengthening in eye-health system development, WHO and Sight 
Savers are in close cooperation within this country. 

The action elements that have been developed especially for the 
peninsula, may require new dimensions in planning and may become 
a new model in the region. The health infrastructure of Malaysia 
is rather well developed, and good inland transport and a better 
standard of living may also be favorable to the success of the pro- 
grams. With a thriving economy now very much in evidence, 
Malaysia should expect to provide high-quality care and self- 
sufficiency in her blindness prevention programs. 


INDONESIA 

In 1982 a survey carried out in eight provinces throughout Indonesia, 
a nation widespread across the Western Pacific with a population 
of 170 million, showed a blindness prevalence of 1.2 percent. The 
chief causes of blindness were: 


Cataract 76.0% 

Corneal Disorders 13.0% 

Glaucoma 10.0% 

Refractive Problems 0.6% 

Retinal Disorders 0.3% 


Keratomalacia and trachoma have become uncommon since 
1980. 

The government’s policy to reduce the prevalence of blindness 
includes integrating eye care throughout primary health care. The 


Western Pacific 111 


secondary and tertiary health-care systems were included in its five- 
year development plan for 1984 through 1989. 

The operation concept is for eye health for all by the year 2000. 
This concept is translated into the carrying out of eye care and POB 
projects through the PEC approach, which will be substantially in- 
creased in the five-year plan for 1989-94, and will involve the govern- 
ment, the private sector, and the community. 


THAILAND 

Thailand occupies 500,000 square kilometers and has a population 
of 52 million of which 80.0 percent live in the rural areas. Unfor- 
tunately, this country has a significant backlog of untreated cataract 
blind. An epidemiological survey in 1986 revealed 0.7 percent 
blindness. The chief causes of blindness were: 


Cataract 

67.7% 

Corneal Disorders 

10.6% 

Optic Atrophy 

7.0% 

Retinal Disorders 

2.7% 

Glaucoma 

2.3% 

The National Institute of Public Health Ophthalmology was 


established in 1983 to provide coordination of a national plan for 
the prevention of blindness. The commencement of these preven- 
tion activities brought about significant ophthalmic programs. Eye 
clinics have increased outside metropolitan Bangkok and the number 
of ophthalmologists has increased from 70 to over 200 and cataract 
operations have increased from 4,000 per year to 20,000 in 1987 and 
30,000 in 1988, when additional surgeries were performed in the 
provinces to celebrate the King’s sixtieth birthday. Thailand hopes 
to have a marked reduction in its cataract backlog within five years. 


BLINDNESS PROBLEMS IN RESOURCE NATIONS 
IN THE WESTERN PACIFIC 

Japan, Australia, New Zealand, and Singapore have eye-care ser- 
vices that are sophisticated and comprehensive. Only small groups 
within these populations are underserved. However, these countries 


112 Plenary Session II— I APB Regional Progress Reports 


increasingly face the problems of the aged blind. As shown in re- 
cent studies in Australia and Japan, the majority of blindness is 
in those over 60. Age-related macular degeneration was diagnosed 
in 43 percent of those applying for services from blind agencies. 
The mean age of those applying was 78-79; women outnumbered 
men three to one, reflecting a longer life expectancy for women. 
As Dr. Vyas has said, research into irreversible blindness must re- 
main a major task worldwide. 


CONCLUSION 

Japan, Australia, New Zealand, and Singapore have particularly 
great potential to contribute resources to the nations of the Western 
Pacific Region. Both academic departments and ophthalmic 
professions have become increasingly committed to training and 
helping to develop strategies to cooperate and assist nations in 
preventative, curative, and rehabilitation programs in the region. Drs. 
Nakajima, Konyama, Newland, Taylor, Galbraith, and Lim are ex- 
amples of the commitment. 

In-country programs in the developing nations of the South 
Pacific Subregion now show potential for developing infrastructure 
that will allow them to be increasingly self-sustaining. In addition, 
with the emergence of potential national leaders in prevention of 
blindness such as Dr. Bage Yaminao demonstrating the inherent 
strength of many island nations in the southern area of the Western 
Pacific, the future seems assured. However, funding the right pro- 
gram will remain a problem. 

Due to their relative affluence the countries in the Western Pacific 
can continue in a position of self-sufficiency in their prevention of 
blindness programs. The WHO and NGOs have helped in the assess- 
ment of blindness in early surveys. Using their collective will, govern- 
ments and NGOs can cooperate to implement prevention of blind- 
ness targets that have already been identified. The impact of 
ophthalmic technology on mass blindness can be achieved by the 
turn of the century. 


PART 4 


PLENARY SESSION III 

Sustainable 
Manpower 
Development 
for Blindness 
Prevention 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 











■ 




























. 

















1 


Ophthalmic Manpower in 
Sub-Saharan Africa 

Dr Allen Foster 

The availability of ophthalmologists varies greatly from one region 
of the world to another, with approximately 1 ophthalmologist per 
20,000 population in North America and Western Europe but less 
than 1 per 1 million in some countries of Africa. 

Two recent workshops have been convened by the World Health 
Organization. The first, for Anglophone Africa, met in 1988 in Ac- 
cra, Ghana; and the second for Sub-Saharan Francophone Africa 
was held in Lome, Togo. Both of these workshops specifically re- 
viewed the current situation regarding ophthalmic manpower for 
eye-care services in Africa. 


OPHTHALMOLOGISTS 

Within Africa there is a wide variation from country to country 
on the availability of ophthalmologists, ranging from 1 per 130,000 
in South Africa to 1 per 3 million in Angola. In general, however, 
in Sub-Saharan Africa there is approximately 1 ophthalmologist 
per 1 million people in Anglophone and Francophone areas, and 
1 per 2 million in Portuguese-speaking countries. Most ophthal- 
mologists work in university teaching hospitals or larger cities. 
Approximately 25 percent of ophthalmologists working in Sub- 
Saharan Africa are expatriates. 

Postgraduate training programs for ophthalmologists exist in 
Senegal, Mali, Ivory Coast, and Zaire for Francophone countries 
and in Nigeria, Ethiopia, Sudan, Kenya, Tanzania, Zimbabwe, and 
South Africa for Anglophone countries. There is no full-time train- 
ing program for Portuguese-speaking countries. Approximately 70 
ophthalmologists graduate each year from 14 training centers in 


115 


116 Plenary Session III — Sustainable Manpower Development 

Africa: 20 are from Nigeria, which has 6 centers, and 20 from South 
Africa, which has 3 centers. 

Although, in the last 10 years there has been an increase in the 
number of ophthalmologists being trained in Africa, they still have 
not been able to keep pace with the increased demand for eye-care 
services, particularly in rural Sub-Saharan Africa. To help solve this 
problem, current initiatives include plans to develop a two-year 
Diploma in Ophthalmology course for Anglophone West-African 
countries, under the direction of the West-African College of 
Surgeons. There is also a proposal to upgrade the present one-year 
Diploma in Ophthalmology course in Zimbabwe to a three-year post- 
graduate training program in ophthalmology. 

Present post-graduate training in ophthalmology in Africa is 
often based on the curriculum for training programs in Europe. 
Because of the different ophthalmic disease patterns and the 
availability of resources, more attention needs to be paid to aspects 
of community ophthalmology in the training of ophthalmologists 
for work in Africa. At present, there is no specific training course 
in community ophthalmology in Africa, but rather, two courses have 
been developed at WHO Collaborating Centers for Blindness 
Prevention, one in London at the International Centre for Eye 
Health and the other in Baltimore at the International Center for 
Epidemiologic and Preventive Ophthalmology at the Johns Hopkins 
School of Hygiene and Public Health. These courses are aimed at 
training ophthalmologists in community or public health 
ophthalmology with a view to establishing and assisting in the 
development of national prevention of blindness programs in their 
own countries. 


GENERAL PHYSICIANS/SURGEONS 

To promote better eye surgical services in some African countries, 
general medical doctors have learned how to perform cataract 
surgery. This practice has been more common in non-governmental 
medical services than in government systems. The problem with this 
approach is that, because of the many other demands on his time, 
the general doctor usually cannot devote enough time to eye-related 
work to develop a sustainable eye-care service. In some remote area, 
however, a general physician or surgeon who has learned cataract 


Sub-Saharan Africa 117 

surgery may be the only possibility in the foreseeable future for pro- 
viding cataract surgery services. 


OPHTHALMIC ASSISTANT/CATARACT SURGEONS 

Because of the inadequate number of ophthalmologists per popula- 
tion, many African countries have now established training pro- 
grams for ophthalmic assistants to provide eye-care services for a 
population of approximately 250,000 people. Ophthalmic assistants 
are usually medical assistants or nurses who have previous general 
medical or nursing training and who are given a specific one-year 
training program in diagnosing and managing common ophthalmic 
problems. Such training programs for ophthalmic assistants or 
ophthalmic nurses currently exist in Ethiopia, Kenya, Uganda, Tan- 
zania, Malawi, Sudan, Mali, Ghana, and Sierra Leone. 

After they have worked for several years, selected ophthalmic 
assistants who have shown very good judgment and superior surgical 
skills may be offered a further one-year training course in cataract 
surgery on a one-to-one basis with an experienced ophthalmologist. 
This training should include performing at least 100 cataract opera- 
tions under supervision before being allowed to practice cataract 
surgery. The training is specifically in intracapsular cataract surgery 
under local anesthesia using magnifying loupes for uncomplicated 
senile cataract. Such training of ophthalmic assistants in cataract 
surgery has been successful in several East African countries 
including Kenya, Malawi and Tanzania. A program is currently 
planned for Mali. 


SUMMARY 

The average ophthalmologist in Africa performs less than 300 
cataract operations per year. This amounts to about 50,000 blind 
cataract patients being operated on per year in Sub-Saharan Africa, 
with an estimated backlog in excess of 3 million cataract blind and 
an annual incidence in excess of 500,000 people per year. The pres- 
ent available manpower, resources, and efficiency are therefore pro- 
viding services for less than 10 percent of the newly blind cataract 
patients and ignoring the problem of the existing cataract blind. 

The major problem related to the development of prevention 
of blindness programs in Sub-Saharan Africa is the lack of trained 


118 Plenary Session III— Sustainable Manpower Development 

manpower. Although efforts are being made to train more ophthal- 
mologists, it is likely that with the present three-year training pro- 
gram for ophthalmologists in African countries, there will be an 
insufficient number of ophthalmologists available outside the larger 
cities in the next 10 years. It is therefore very important that ex- 
cellent supervised-training programs be developed for ophthalmic 
assistants or ophthalmic nurses who can provide the basic eye-care 
services to rural populations in Africa and who may also be trained 
to deliver cataract surgery services. Consideration should also be 
given to promoting one-year courses in ophthalmology for African 
doctors to develop expertise in eye diseases and to specifically train 
in cataract surgery. Precise needs in the next decade are: 

1. Development of regional training centers for ophthalmolo- 
gists in: 

• Anglophone West Africa 

• Francophone West Africa 

• Central and Southern Africa 

• Portuguese-speaking countries 

2. Establishment of one-year training programs in Africa for 

doctors to train as eye doctors/cataract surgeons. 

3. More emphasis given to the training of selected ophthalmic 

assistants as cataract surgeons in individual countries. 

4. Suggested goals for the next decade to be discussed are: 

• One national ophthalmologist per 500,000 population 
in every African country. 

• One cataract surgeon (eye doctor or ophthalmic assis- 
tant/cataract surgeon) per 250,000 population in every 
African country. 

• A cataract surgical rate of at least 1,000 operations per 
million population in African countries. 


2 


Training Doctors in 
Community Ophthalmology 

Dr Rabiul Husain 

Bangladesh is one of the least developed countries with an area of 

144.000 square kilometers inhabited by 110 million people with a 
per capita annual income of $163. Of the many problems confront- 
ing Bangladesh in the health sector, the problem of blindness is one 
of the most important. Unfortunately, various factors, such as re- 
source constraints, lack of skilled manpower, and the physical and 
social remoteness of existing facilities, contribute to this problem. 

The country has a very limited number of ophthalmic resources 
and there is only 1 ophthalmologist for every 1 million people. The 
same ratio is true even for ophthalmic support staff. There are a 
total of 1,500 ophthalmic beds in both government and non- 
government hospitals. Because of the agriculture-based economy, 
80 percent of the population lives in rural areas. However, all of 
the ophthalmic facilities are located in cities and towns, thus ag- 
gravating the situation. 

A great majority of blindness can be prevented provided timely 
and appropriate measures are undertaken and a significant number 
of blind people can be cured by surgical intervention. Cataract is 
one of the major causes of curable blindness. According to a con- 
servative estimate, there is a backlog of nearly 500,000 cataract cases 
in need of surgical intervention. Every year there are an additional 

50.000 to 60,000 new cases of cataract, glaucoma, ocular infection, 
trauma, and nutritional blindness — all of which are major prevent- 
able causes of blindness. 

With the goal of overcoming the acute shortage of ophthalmic 
manpower in the country, the Eye Infirmary and Training Com- 
plex of the Bangladesh National Society for the Blind embarked 
in 1979 on a program to train doctors. The Doctors’ Training Pro- 
gram in Community-Oriented Ophthalmology was initially to be 
a one-year course, but it was soon discovered that the trainees needed 


119 


120 Plenary Session III — Sustainable Manpower Development 


more practical experience to make them dependable cataract 
surgeons. Therefore, a well-designed two-year course was eventually 
developed under the auspices of the University of Chittagong, which 
leads to a Diploma in Community Ophthalmology. 


First Year: 

Residency Training (12-month duration) 

First Phase 
(3 Months) 

Orientation classes, clinical clerkship, and learn- 
ing basic clinical skills. 

Second Phase 
(4 Months) 

Exposure to operation theater techniques, the out- 
patient department, and mobile eye camps. 

Third Phase 
(5 Months) 

Specific responsibilities in the ward, outpatient 
department, and operation theater (extra-ocular 
surgery), plus participation in the mobile school 
clinic, primary eye-care program, and nutrition 
rehabilitation program. 

Evaluation 

At the end of each phase. 

Second Year: 

Diploma in Community Ophthalmology Course 
(12-month duration) 

First Phase 
(3 Months) 

Lectures and tutorials — 160 Hours. Practicing 
clinical skills with inpatients and outpatients and 
in the operation theater (including intraocular 
surgery). 

Second Phase 
(4 Months) 

Participation in the eye camp program, indepen- 
dent responsibilities in various departments and at- 
tending patients. 

Third Phase 
(3 Months) 

Independent responsibilities of indoor and outdoor 
patients, practicing intraocular and extraocular 
surgeries, and participation in tutorial classes, 
clinical meetings, and Journal Club meetings. 

Fourth Phase 
(6 Weeks) 

Refresher course, final evaluation, and final 
examination. 


Each trainee is to perform and maintain a detailed record of 
at least 150 cataract surgeries and also 16 cases of common 
ophthalmic problems presented in the hospital. 


Training Doctors in Community Ophthalmology 121 

Thus far, 79 doctors have received training in community 
ophthalmology and are actively engaged in the prevention of blind- 
ness program in this country. 

The success of this program is that in the year 1973 only 1,600 
cataract cases were operated upon. However, the gradual increase 
of trained manpower, including both doctors and ophthalmic 
paramedics, has resulted in nearly 50,000 cataract surgeries under- 
taken in 1979 by this organization. 

The significant development in this field is that the University 
of Chittagong has recently marked the success of the program by 
establishing an Institute of Community Ophthalmology, so that 
training of doctors in community ophthalmology can be further 
developed to serve the region. 



















. 




. 










3 


Sustainable Manpower Development 
for Blindness Prevention 

Dr. Moses C. Chirambo 

AUXILIARY SUPPORT: OPHTHALMIC ASSISTANTS 

A particularly worrisome problem in Sub-Saharan Africa is lack 
of trained eye-care personnel. In many countries of the region, there 
is 1 ophthalmologist per 1 million population. Although efforts are 
being made to train more ophthalmologists, it is unlikely that there 
will be sufficient ophthalmologists available outside urban areas. 
It is therefore obvious that ophthalmologists in Africa must delegate 
much of their routine work to other eye-care personnel who are more 
readily available. It is also equally important that good training pro- 
grams are developed for ophthalmic assistants, who can provide 
basic eye-care services to rural populations. 

To overcome constraints inherent to the region, several coun- 
tries have recognized the need to develop national or subregional 
training programs for ophthalmic assistants. The ophthalmic assis- 
tant is a qualified nurse or medical assistant (clinical officer) who 
has had several years of experience in medical work before being 
selected for specific training in ophthalmology. 

The training lasts 12 months and consists of instruction in basic 
sciences, pathology of common eye conditions, epidemiology, how 
to perform an eye examination, and management of common eye 
conditions. This training is performed by ophthalmologists who have 
experience in relevant eye diseases and takes place in established 
eye units that have a sufficient patient load, adequate facilities, and 
appropriate training materials. 

Upon completion of the training, the ophthalmic assistant is 
expected to diagnose and manage all common eye conditions, rec- 
ognize and refer those conditions that require more sophisticated 
care, organize and run outreach and static clinics, and provide educa- 
tion on primary eye care, including health promotion and prevention 


123 


124 Plenary Session III — Sustainable Manpower Development 

of eye disease. He is also expected to select patients for surgery, 
perform extraocular surgery, properly use a direct ophthalmoscope, 
provide tonometry, administer subconjunctival injection, remove 
foreign bodies, and distribute necessary drugs. 

On graduation the ophthalmic assistant is provided with 
diagnostic and surgical equipment and posted to a district clinic. 
It is necessary that he or she is supervised and supported by an 
ophthalmologist regularly. The ophthalmic assistant acts as the link 
between patients with eye problems in rural communities and the 
ophthalmologist in the referral centers. 

Currently, training programs for ophthalmic assistants have been 
established in Ethiopia, Ghana, Kenya, Malawi, Sierra Leone, Tan- 
zania, and Uganda. Soon Lesotho and Zimbabwe will establish train- 
ing programs for ophthalmic nurses. The goals for the future are 
to develop more ophthalmic training programs for ophthalmic 
nurses and to reach a target of 1 ophthalmic assistant per 100,000 
population. Thus far, the constraints to these goals have included 
problems in achieving recognition of the program’s qualifications, 
providing sufficient standardization, and the lack of incentives after 
training. 


4 


Sustainable Manpower Development 
for Blindness Prevention: 

Nepal 1981-90 

Dr. G.P. Pokharel 

Nepal has a population of 18 million people and an area of 147,181 
square kilometers roughly divided into three geographical regions. 
A vast plain called the Terai has 45 percent of the population and 
most of the roads with relatively easy access. The hills have 47 per- 
cent of the population, and the mountainous region has 8 percent 
of the population. The country has a literacy rate of 25 percent and 
a per capita income of $160 per year. The life expectancy is 52 years 
and the infant morality rate is 108 per 1,000. 

Before 1980 the country had 8 eye surgeons with a total of 28 
beds to serve a population of 13 million. Approximately 1,500 
cataracts were performed every year in the Kathmandu hospital, 
three rural eye departments, and scattered eye camps. However, in 
1980-81 the World Health Organization and the Seva Foundation, 
with the help of several other donor agencies, joined the Govern- 
ment of Nepal to conduct a blindness survey. The survey’s major 
findings were the following: 

1. An estimated 117,620 people (0.8 percent) were blind. 

2. 23,610 people (1.7 percent) were blind in one eye. 

3. 92.0 percent of the blind resided in rural areas of the country. 

4. 80.0 percent of this blindness was avoidable, that is, it was 
either preventable or curable. 

The major cause of blindness in Nepal was found to be cataract, 
which accounted for 66.8 percent of the total blindness. With the 
above data in mind, the Government- and WHO-sponsored Pre- 
vention and Control of Blindness Project had as its ten-year na- 
tionwide program the objective of national self-reliance in ophthal- 
mic care. 


125 


126 Plenary Session III— Sustainable Manpower Development 

To attain this target, the following principal strategies have been 
employed: 

1. Establish eye centers/hospitals in those rural areas that were 
the least served. 

2. Train: 

• more eye surgeons — 50 by the end of decade. 

• 200 ophthalmic assistants. 

• district medical officers, paramedics at the Health Post 
level, and primary health-care volunteers at the village 
level. 

3. Increase the number of mobile camps in which surgery for 
cataract and trichiasis/entropion are performed. 

4. Establish a training program for ophthalmic assistants in 
Nepal. 

5. Conduct field surveys, enacting preventive and curative 
measures for xerophthalmia and trachoma. 

6. Train health post paramedics, village-level primary health 
workers, and volunteers in primary eye care. 

The first group of 46 ophthalmic assistant trainees was selected 
in 1981 after interviewing 720 candidates. The trainees were selected 
primarily from remote rural areas so that there would be no dif- 
ficulty for them to work in rural areas after training. 

Three months of intensive theory classes were conducted and 
every month an assessment was made of the trainees regarding their 
knowledge. Classes on some subjects were repeated when necessary. 
Ophthalmologists, physicians, public health specialists, and health- 
education experts took part in the training. Handouts were prepared 
and regularly distributed in every class. The curriculum was revised 
by Drs. Kolstad, Pararajasegaram, Mohan, and Khosla, among 
others. Prof. Khosla prepared a manual which proved to be most 
useful. After three months, a final theoretical examination was con- 
ducted. Nine of these 46 trainees received a one-year training course 
at the Aravind Eye Hospital in Madurai, India. 

The bulk of the trainees then received on-the-job training for 2.5 
years in rural areas. The training consisted of hospital-based train- 
ing, which includes: 1) diagnosing common eye conditions like cat- 
aract, glaucoma, iritis, conjunctivitis, pterygium, chalazion, refrac- 
tive error, and others; 2) assisting in the operating theater, including 


Sustainable Manpower Development in Nepal 1981-90 127 

asepsis and sterility; cleaning and autoclaving instruments; using 
local anesthesia — surface, retrobulbar, and facial; and assisting in 
surgery; 3) using minor surgical techniques, including entropion/ 
trichiasis, pterygium, and chalazion. Mobile Camp training includes 
detection and treatment of trachoma, eye-health education, treat- 
ment and detection of xerophthalmia, and entropion surgery. 


HEALTH EDUCATION TRAINING PROGRAM 

Nepal Netra Jyoti Sangh (NNJS), with the help of the Seva Founda- 
tion, started a training program in health education in 1986. These 
trainees were mostly ophthalmic assistant supervisors who were 
working in rural eye centers. The initial training focused on under- 
standing the eye-care materials to be distributed to those attending 
eye camps. Along with this program, a nationwide radio program 
was established that, among other things, announced the dates 
of upcoming eye camps and discussed topics regarding blinding 
eye diseases. 

In 1988 NNJS established a health education unit with the finan- 
cial support of Seva. It now has two ophthalmic assistant super- 
visors who work as senior health educators. This unit has started 
publication of a quarterly newsletter and eye-health education 
material on common eye diseases. 

Depending on their skills and maturity, several ophthalmic as- 
sistants have been trained to perform specific tasks in different 
eye centers. These include administration management and 
record-keeping. 

The ophthalmic assistants who received the above training have 
fit nicely into the eye hospital and have performed many different 
types of jobs. Whenever a person is required for a specific task in 
the hospital, it is wasteful to routinely use an ophthalmic assistant. 
Visual acuity testing and other such relatively simple tasks should 
be relegated to auxiliaries. Ophthalmic assistants and auxiliaries 
interact effectively with ophthalmologists and periodic supervision 
has been provided by the latter. Monthly staff meetings are held 
to discuss programs of mutual concern. 


PRESENT SITUATION 

All ophthalmic assistants are able to carry out routine outpatient 


128 Plenary Session III — Sustainable Manpower Development 

department (OPD) procedures, provide operation-theater assistance, 
and organize eye-camp activities. Over 80 percent are competent 
in routine refraction. Twelve are supervisors who conduct OPD ser- 
vices in rural eye hospitals and district eye clinics. These 12 also 
perform routine administration and management tasks in the district 
eye clinics. Three ophthalmic assistants have received further training 
in community ophthalmology and are directing field programs in- 
dependently. Two are working on pharmaceutical production of eye 
drops and a few on manufacturing of glasses. Finally, one has 
become a maintenance engineer of ophthalmic instruments and 
equipment. 

Along with the progress in this category of manpower develop- 
ment, the country now has 45 ophthalmologists, 13 rural eye 
hospitals (with 728 eye beds), and 12 district eye clinics. More than 
27,000 cataract operations are performed every year through the 
combined efforts of the eye centers and mobile teams. This increased 
productivity in Nepal as compared to other countries in the region 
has been largely due to the hard work, skills, and efforts of the 
ophthalmic assistants. 


CONCLUSIONS 

1. Although it can vary from center to center, ophthalmic 
assistants are able to perform at least 60 percent of the tasks 
of ophthalmologists in rural centers. 

2. For any expansion and implementation of a field program 
on prevention of blindness, this type of manpower is ab- 
solutely necessary. 

3. Career development opportunities and continuing education 
must be provided. 

4. Curriculum and training manuals should be required by the 
country concerned. 


5 


Development of Management Personnel 
in Blindness Prevention 

Mr R.D. Thulasiraj 

INTRODUCTION 

In a program that addresses public health issues, the emphasis needs 
to be on program management. The clinical or medical aspect of 
the intervention is normally a well-established procedure, for ex- 
ample immunization or cataract surgery, and there is little reason 
to change the basic design of the medical intervention. However 
the delivery of the intervention and its organization will need to 
be adapted to suit the public health need. The real challenges come 
in social marketing to create a demand for services, generating 
resources, getting organized to meet the demand, taking care of 
logistics, evaluating the program’s effectiveness, analyzing successes 
and failures, planning, developing manpower, and seeing to a host 
of other issues. All of this requires knowledge and skill that are 
quite different from treating a patient who has come to the hospital 
on his or her own initiative. As the emphasis on the community- 
oriented approaches increases, the need for this type of manpower, 
with program management expertise, becomes more critical. 


ISSUES IN HEALTH MANAGEMENT TRAINING 

Though there is a need for management specialists in any large 
public health program, there cannot be a clear demarcation of the 
management function between clinical and non-clinical personnel. 
Some of the clinical personnel, especially those at the senior level 
will need to possess considerable managerial ability to make the 
team work better. 

This raises an important issue of who should be in charge of 
a program. In the Asian context, and probably most others, the 
ophthalmologist is looked upon as the leader of the program. 


129 


130 Plenary Session III— Sustainable Manpower Development 

Whereas it may not be efficient to perpetuate the present practice 
of using the ophthalmologist as the program manager, the reality 
that this is often the case will need to be recognized in the training 
and positioning of health management personnel. 

Apart from the above external perception, there is also an in- 
ternal perception among ophthalmologists that they should be in 
charge because their medical education is considered superior to 
other training. These perceptions are further reinforced by the tradi- 
tion of medical doctors becoming, often through seniority, the heads 
of hospitals and health-care programs. In instances where profes- 
sional managers have been placed in senior or parallel positions 
to the doctors, there has often been conflict that negatively affected 
the program. 

Another dimension to the proper development of health manage- 
ment personnel is the environment of health management in the 
country and the level of its sophistication. This is particularly im- 
portant because we have to recognize that the training must be ap- 
propriate to the needs, culture, and the working environment of 
that particular country. 

In India and most developing countries the management role 
in health is perceived to be at a very low level and is often limited 
to following routine procedures, many of which were established 
many years ago. Supervisory skills at the departmental level, such 
as medical records, housekeeping, stores, and finance, are also in 
need of considerable improvement. Concepts of social marketing, 
operations research, scientific human resource development, and 
strategic planning processes are usually nonexistent. The develop- 
ment of health management personnel needs to reflect these needs. 

CURRICULUM 

Curriculum development needs to be viewed within the framework 
of the reality described above. For senior clinical personnel there 
needs to be a process of sensitization and appreciation of managerial 
inputs. For health management personnel the curriculum and train- 
ing philosophy should reflect the relevance and appropriateness of 
the country’s needs. 

MANAGEMENT PERSONNEL IN EYE CARE 

Whereas the clinical aspects of curing and treating ocular morbidity 


Development of Management Personnel 131 

has been well developed, its delivery to the masses, using an ap- 
propriate methodology and technology at an affordable price, still 
remains a major challenge. 

To meet this challenge, management training will need to be im- 
plemented at the following three levels: ophthalmologists and clinical 
personnel, senior program managers, and supervisory personnel. 


Ophthalmologists and Clinical Personnel 

The management process is a team effort even when there are 
separate administrative personnel charged with that responsibility. 
To this end the clinical personnel need to be sensitized to the manage- 
ment process and gain a reasonable understanding of it. Exposure 
to the elements of social marketing, such as epidemiology and social 
behavior, will give the clinical staff an understanding of the 
magnitude of the blindness problem and the problems involved in 
delivering eye care to them. This exposure ensures greater involve- 
ment of the clinical staff and development of an appropriate social 
marketing process. The same kind of benefits can be gained from 
their exposure to operations research approaches to increasing in- 
ternal efficiency and other management processes. 


Senior Program Managers 

The training of senior management personnel will need to focus 
on two broad areas: external environment and internal resources. 

External Environment 

The management of the external environment consists of: 

• Social marketing, which involves knowing the magnitude and 
characteristics of the problem, as well as relevant behavior pat- 
terns, economic issues, and logistical issues. The training tools 
appropriate to provide the necessary skills and knowledge in- 
clude: core epidemiologic principles, epidemiology of blind- 
ness, basic biostatistics, health behavior, health education, and 
health economics. 

• Resource mobilization, which involves both financial and 
human resources, depends on the character, scope, and size 
of the program. Specific skills and knowledge that are useful 


132 Plenary Session III — Sustainable Manpower Development 

in this area include: financial planning and management, na- 
tional blindness policy and funding, the role and available 
funding opportunities of international NGOs in that nation, 
and human resources development and manpower planning. 


Internal Resources 

Management of resources is a vital process in developing coun- 
tries due to their scarce availability. The main resource categories 
include manpower; physical facilities such as beds, operating rooms, 
and equipment; and money. The training should include the follow- 
ing subjects: operations research, basic principles of industrial 
engineering, maintenance management, accounting and budgetary 
control, inventory management, personnel management, and under- 
standing of support departments such as housekeeping and medical 
records. 


Supervisory Personnel 

Within an eye-health program, specialized supervisory skills are 
required in several areas, such as medical records, stores, housekeep- 
ing, computers, accounts, out-reach coordination, and health educa- 
tion. In certain countries such personnel are readily available, but 
in others they need to be trained. 

Although three levels of management training have been iden- 
tified, three levels of personnel are not always necessary. The level 
and number of personnel depends entirely on the size of the pro- 
gram. For instance in small programs the program management and 
several supervisory roles could be handled by one person. Whereas 
in large programs it is possible that there must be several senior 
program managers, each handling a specialized function under an 
overall coordinator. 


TRAINING PHILOSOPHY 

Because the immediate need is for manpower that can manage pro- 
grams efficiently, the training program needs to be applications 
oriented. The managers will also need to establish a conceptual 
framework so that there will be no conflict between long-term ob- 
jectives and short-term achievements. Such training can be accom- 


Development of Management Personnel 133 

plished through a careful blending of classroom teaching in a prac- 
tical setting where the students can consistently apply what they 
are learning. 

However, there is the pitfall that such a training course could 
result in strong supervisors who nevertheless have poor entre- 
preneurial skills, which are very vital for continued excellence of 
any program. This can be addressed very effectively at the selec- 
tion stage and later during training by involving the students in proj- 
ects that call for strong developmental activity. An outcome-oriented 
approach with an emphasis on problem solving during training will 
help to develop good managers. 


CONCLUSION 

The management training process for eye-health program must 
reflect program needs and the health management culture. Although 
it is necessary to teach general subjects, such as epidemiology, 
biostatistics, and operations research, it is even more important to 
make them specific to the country’s needs through an appropriate 
practical setting. 



6 


Management of an Eye-Care Program 
in a Developing Country 

Mr. Samuel K. Tororei 

INTRODUCTION 

I believe that the greatest challenge facing us as providers of eye- 
care services in this decade is the need to manage an ever-diminishing 
amount of resources to provide for an ever-increasing demand for 
our services. Difficult choices must be made at every turn, with the 
knowledge that the decisions of today will affect the outcomes of 
tomorrow. 

It is therefore necessary to develop programs that are sustainable, 
and the surest way to make a program sustainable is to design sound 
management and administrative procedures and organs. These pro- 
cedures and organs must be adequate for the needs of today, while 
being forward-looking enough to be ready for the challenges of 
tomorrow. 

In answer to the question of how we can best manage our eye- 
care programs, I argue that the best alternative at our disposal is 
the national Prevention of Blindness Committee, which has dem- 
onstrated its usefulness in Kenya for the last quarter of a century. 

The observations contained here are entirely mine, and in no 
way represent the views of the Kenya National Prevention of Blind- 
ness Committee or the Kenya Society for the Blind. 


A HISTORICAL PERSPECTIVE 

In the 1960s and 1970s, the importance of eye-care programs, par- 
ticularly at the national level, gained increasing recognition, among 
non-governmental organizations, as well as among national min- 
istries of health, who soon realized the fruits of organized provision 
of both preventive and curative eye services. Eye-care programs pro- 
vided a meeting point between various eye-health providers, which 


135 


136 Plenary Session III — Sustainable Manpower Development 

soon led to the formation of a national Committee for the Preven- 
tion of Blindness in countries that did not have them or this Com- 
mittee’s reappraisal in countries that did. 

This process gained momentum as the international agencies 
interested in eye care rallied behind the banner of the International 
Agency for the Prevention of Blindness, which was formed in 1975 
in official relationship with the World Health Organization. In turn, 
the World Health Organization added its voice to the need and 
desirability of national eye-care programs, particularly within the 
context of primary health care. Thus, as the 1980s were ushered in 
with such momentum, the United Nations announcement that 1981 
would be the year of disabled persons, and subsequently that the 
rest of the decade would be dedicated to disabled persons, preven- 
tion and cure of blindness was no longer a matter only for NGOs 
but also for governments and the United Nations system. 

As their significance increased, so did the size of eye-care pro- 
grams, and soon it was necessary to deal with important manage- 
ment issues. The purpose of this paper is to discuss the most salient 
management issues likely to be encountered during the operation 
of an eye-care program in a developing country and to emphasize 
the need for a practical approach to the resolution of management 
conflicts. Extensive use will be made of the Kenya experience. 
However, reference will be made to many other African programs 
with which I have come into contact through the joint meetings 
of the national committees for the prevention of blindness of East 
African countries and the Non-Governmental Forum for East and 
Southern Africa, a group that brings together societies for the blind 
in those areas of Africa. Although the examples used in this paper 
are from Africa, I believe other developing countries will find them 
applicable to their circumstances. 


ORGANIZATIONAL AND ADMINISTRATIVE STRUCTURE 

Eye care is part of the general health program of any country and 
is therefore subsumed under whatever ministry is responsible for 
health. However, in the overall order of priorities, eye care is not 
always at the top in any ministry of health because ministries and 
indeed governments all over the world are more concerned with 
problems of life and death. Usually blindness does not fit into that 


Management of an Eye-Care Program 137 

category. Eye care must therefore fight for its share in the ministry’s 
resources from a disadvantaged position. 

Providers of eye care within and outside the ministries of health 
are very conscious of this problem; and this may explain why in 
many countries, eye care is the only health service with a five-year 
plan or an established committee. (This was certainly true of nearly 
all countries before the advent of AIDS in the past few years.) Thus, 
it is my contention that by reason of its priority status, eye care 
demanded a radical approach, which we in Kenya took advantage 
of as early as the mid-1960s and which the rest of Africa adopted 
in subsequent years. 

The major results were: 

1. The non-governmental organizations (NGOs) were accepted 
by the ministries of health as important partners and were 
therefore incorporated into the ministries’ policy-making 
organ. This makes the participation of the NGOs interested 
in eye care different from the participation of those engaged 
in other sectors that usually tend to go it alone or at best 
develop tentative relationships with the ministries of health. 

2. The chief NGOs interested in eye care were willing to put their 
resources and skills at the disposal of the ministries of health 
and to treat this as a health arrangement between more or 
less equal partners. In turn, the ministries allow the NGOs 
to participate not only in policy formulation but also in policy 
implementation. 

3. The partnership is still in the process of developing in some 
countries, which has been built on these two factors. In coun- 
tries where the process has been completed, for example in 
Kenya, Tanzania, and Uganda, the partnership between the 
ministries of health and the major NGOs has been formalized 
through the national Prevention of Blindness Committee. 
Such committees provide for power-sharing between all par- 
ties concerned, with the ministry of health clearly having the 
final say but with NGOs wielding substantial influence at 
all levels of eye-care service delivery. 

The Prevention of Blindness Committee is by far the best man- 
agement organ for a national eye-care program and should therefore 
form the central pivot around which the eye-care program will 
revolve. How this might be accomplished must now be addressed. 


138 Plenary Session III — Sustainable Manpower Development 

The national Prevention of Blindness Committees are organ- 
ized as follows: 

1. Membership is by organization rather than by individuals. 
Each organization is represented by persons in a position to 
make binding decisions on behalf of their organizations. This 
avoids the need to constantly have to make consultations with 
senior officers. This also allows the national Prevention of 
Blindness Committee to be an efficient management tool and 
enables it to fulfill any management role assigned to it. 

2. The Committee is chaired by a Minister of Health. Because 
it is mandatory for all organizations to send senior officers 
to the Committee, the ministries of health usually oblige by 
sending officers at the level of Deputy Director of Medical 
Services or higher as chairman to the Committee. It is not 
always possible to ensure that this officer is an ophthal- 
mologist, nor is it always desirable that this be the case. 
Therefore, the chairman is usually advised by the govern- 
ment’s Chief Ophthalmologist and other officials. By virtue 
of the seniority of the chairman and his Ministry colleagues, 
the Committee’s decisions are more likely to receive the 
Ministry’s approval than would be the case otherwise. 

3. The Committee’s secretariat is provided by the non- 
governmental organization sector. This is usually done 
through the National Society for the Blind, which not only 
provides the secretary to the Committee, in the person of its 
chief executive or an officer designated by him, but also the 
physical office space and administrative backing for the pro- 
gram. This gives the Committee administrative flexibility. 

4. The professional workers are represented in a subcommit- 
tee, which deliberates on all professional matters on behalf 
of the main Committee. Representation is organized in such 
a way as to ensure the widest participation by all categories 
of eye workers, without overloading the Committee with 
numbers. 

5. Organized as stated above, the Committee is able to require 
all parties interested in eye care to inform it of their projects 
and thus be able to oversee the entire ophthalmic program 
in the country. 


Management of an Eye-Care Program 139 

Before attempting to establish a prevention of blindness com- 
mittee in your country, you may wish to consider the following 
questions: 

1. Is there a Ministry of Health in your country? 

A strange question perhaps, but nonetheless important to 
consider. Experience has shown that it is undesirable to by- 
pass the government in the development of any national pro- 
gram, if that program is to achieve the greatest success. The 
central Ministry or Department of Health must be charged 
with the overall responsibility for the national eye-care pro- 
gram. This Ministry will be the backbone of a workable 
program; other parties will only supplement what the govern- 
ment does. This ensures that the program remains truly 
national, not private. In large countries like Nigeria it is 
argued that this requirement would be impracticable. How- 
ever, this need not be the case because the highest health 
authority, in this case the federal Ministry of Health, can 
still take responsibility and delegate whatever powers it deems 
to state health authorities, just as it does with other programs. 

2. Must the administrative machinery, the national 
Prevention of Blindness Committee, always be 
at the Ministry headquarters? 

Yes, it is advisable. It is at the Ministry headquarters that 
health policies are made and where resources are shared. In 
addition, we have demonstrated the need for the Ministry 
of Health to assign a senior officer to chair the Committee. 
This can only be practical if the Committee is centered at 
the Ministry headquarters. In the case of very large states, 
a state Prevention of Blindness Committee can be established 
as a subcommittee of the central Prevention of Blindness 
Committee. In such an instance, communication channels 
between the subcommittees and the central Committee must 
be designed to provide a clear link between the two manage- 
ment levels. Kenya’s Prevention of Blindness Committee has 
made both the chairman and secretary of the Professional 
Subcommittee members of the national Committee. Similar 
representation links could be employed between central Com- 
mittees and state subcommittees. In this case, the state sub- 


140 Plenary Session III— Sustainable Manpower Development 

committee would perform the tasks now performed by the 
Professional Subcommittee in the Kenyan scenario. 

3. Can the secretariat be provided by the Ministry of Health? 

In theory this would be the ideal situation. Experience has 
shown however, the Prevention of Blindness Committees 
achieve more flexibility and command more NGO confidence 
when the secretariat is vested in the National Society for the 
Blind. This presupposes that such an organization exists in 
the intending country. This is not always the case. In fact, 
the Ethiopian program is run as part of the Ministry without 
much involvement from the National Association for the 
Blind. The same situation obtains in a general way in Zam- 
bia. The point to note is that in the absence of a National 
Society for the Blind, or in a situation where such an organ- 
ization exists but is unwilling or unable to perform the task 
of secretariat to the eye-care program, the second best alter- 
native is to develop a secretariat service within the Ministry 
of Health, usually by making the eye-care program a separate 
program with its own manager or director as Ethiopia has 
done. The program manager or director would then assume 
secretariat responsibilities on behalf of the program. 

4. Is it necessary to include the NGOs? If so, to what extent? 

Each country has to decide whether or not to take advan- 
tage of what the NGOs can offer to the eye-care program 
and the terms under which to accept this. Experience in 
Kenya, which spans over two decades seem to point to the 
fact that NGOs bring to the ophthalmic program — and in- 
deed to the rest of the Health Service — much valuable ex- 
pertise, backed with flexible resources. These resources enable 
the Ministry to fill the gaps left by an inability to mobilize 
adequate government resources, or alternatively, ministries 
use NGO resources to meet unexpected or short-term needs. 

In Kenya, for example, the eye-care program has man- 
aged to expand rapidly because of inputs from various NGOs, 
whose contributions include the construction of eye depart- 
ments in provincial and major district (government) hospitals, 
equipping of all government eye clinics in the country and 
subsidizing of the National Eye Drops Production Unit, to 


Management of an Eye-Care Program 141 

name but a few. It is therefore clear that NGOs can be made 
useful allies of the national eye-care program, but it must 
be borne in mind that NGOs form a powerful interest group 
which cannot be ignored. Their interests must be taken into 
account when deciding membership to the managing organs 
of the program. Ministries of health must also make general 
rules of conduct through the managing organs of the pro- 
gram, which should be binding to all interested in partici- 
pating in the eye-care program. NGOs should be encouraged 
to view their participation in the eye-care program as supple- 
mentary and hence subordinate to the Ministry of Health. 
In turn the Ministry of Health should lend a sympathetic 
ear to NGO concerns whenever these are raised. The proper 
management of the program relies on the establishment of 
mutually acceptable working partnerships between the 
ministries of health and the NGOs. 

Another subsidiary issue is whether international NGOs 
should be allowed to participate or whether participation 
should be vested only in national or local NGOs. My con- 
sidered opinion is that the category of NGO does not mat- 
ter. The primary qualification is whether or not the NGOs 
aspiring for participation is engaged substantively in the pro- 
vision of eye care in the country. Because it is not expected 
that all NGOs contributing to the eye-care program must par- 
ticipate in the managing organs of the program, each coun- 
try must define what NGOs should fulfill before they can 
be allowed to represent the wider NGO community on the 
managing organs. (A pointer would be to insist on represen- 
tation of, and from the major organizations interested in eye 
care. This would exclude the very small or one of the con- 
tributors whose interests would be represented by the more 
substantial contributors.) The program can also design a form 
of representative rotation, with NGOs serving for a period 
of time and then allowing others to take their place. Whatever 
method is chosen, care must be taken to ensure that NGO 
representation is balanced and satisfactory. 

5. What powers should be vested in the managing organ of the 
eye-care program? 

The managing organ of the national eye-care program is the 


142 Plenary Session III — Sustainable Manpower Development 

national Prevention of Blindness Committee. It should 
therefore be vested with powers to enable it to carry out all 
the managerial tasks required by the program. These would 
include: 

• Power to act as an executive arm of the Ministry of 
Health. This means that the Ministry will accept the 
decisions, recommendations, advice, or proposals of 
the Prevention of Blindness Committee as part of the 
outcome of its own authority and not view these as 
though they came from an outside agency. The Ministry 
must therefore define areas of the Committee’s author- 
ity in the Committee’s terms of reference. These terms 
of reference must also clearly set out the limitations 
of the Committee and the procedure to be followed 
when these limitations are reached. 

• Power to allocate resources within the ophthalmic pro- 
gram. We have noted that the program receives re- 
sources from the Ministry and from NGOs. The Preven- 
tion of Blindness Committee must be empowered to 
receive and allocate these resources so as to ensure that 
all sectors of the program and the country get an ade- 
quate share of available resources. This would imply 
that the Ministry would take seriously the Committee’s 
recommendations of staff deployment, acquisition and 
distribution of eye medicines, acquisition and distribu- 
tion of surgical and diagnostic instruments, appropriate 
equipment for various categories of eye workers, and 
so forth. 

• Power to oversee and regulate the entire program. The 
Committee must be empowered to regulate the whole 
ophthalmic program. Thus the Committee should have 
power to decide the rate of the program’s expansion, 
both vertically and horizontally. For instance, the Com- 
mittee should regulate the establishment of new cadres 
of eye workers as well as the establishment of eye-care 
programs in new geographical locations. 

• Power to monitor and regulate manpower training. The 
success of any eye-care program will largely depend on 
the quality of its workers. The Committee should be 


Management of an Eye-Care Program 143 

empowered to ensure that training programs for these 
workers are of an acceptable standard. This may be ac- 
complished through constant monitoring of the pre- 
service and in-service training programs. 

• Power to formulate the program’s policy. The Commit- 
tee must be empowered to formulate the eye-care pro- 
gram policy within the general guidelines of the overall 
health policy in the country. The Committee would nor- 
mally perform this task through a five-year develop- 
ment plan or other instruments of policy. The policies 
so formulated should receive full Ministry backing and 
in fact should be incorporated into the general Ministry 
of Health overall program. 

• Power to evaluate the eye-care program. Of all the 
powers that the Committee must have if it is to run 
the national eye program, the most important is the 
power to evaluate the program, and by extension, itself. 
The cornerstone of a dynamic program is its ability to 
renew itself through periodic self-examination. This 
process enables the eye-care program to respond to 
changing needs and circumstances in a planned and 
orderly manner. The Committee should evaluate the 
eye-care program constantly with a view to improving 
its performance. 


Possible obstacles in the establishment of a managing 
organ might include the following: 

• Bringing all parties together. A good managing organ 
is an alliance between the Ministry of Health, the Na- 
tional Society for the Blind, other national and inter- 
national NGOs interested in the provision of eye-care 
services, and manpower- training organs within and out- 
side the Ministry of Health, for example the national 
university or universities engaged in the training of 
ophthalmologists. It is not always easy to bring all these 
organizations together to make them subscribe to a 
common set of rules of conduct. Each organization, 
or even sub-sector of the same organization, has 


144 


Plenary Session III— Sustainable Manpower Development 


different perceptions that may not be in agreement with 
the needs of the Prevention of Blindness Committee. 

• Gaining recognition for the Committee. Even when the 
national Prevention of Blindness Committee has been 
set up, it is still necessary to build acceptance not only 
among its members, but also among all those individ- 
uals and organizations involved in the provision of eye 
care both within and outside the “official” or Ministry 
program. It takes time to achieve a definitive status. 
In the process program managers must endure much 
uncertainty and many anxious moments when at times 
the whole purpose of the Committee is called into 
doubt and a collapse of the program seems imminent. 

• Resolving conflicts of interest. As with all partnerships, 
each partner brings into the managing organ its own 
views. For instance, the Ministry of Health may feel 
that a certain NGO input should be directed to some 
aspect of eye care that the concerned NGO is not in- 
terested in, for example construction of an eye clinic 
when the NGO wants to do a series of eye camps. The 
Committee must find ways of compromising through 
mediation. To some extent, conflict can be minimized 
by writing an eye-care program plan that defines pri- 
orities and sets out a timetable for each aspect of the 
program in clear terms. In this way, NGOs will be able 
to decide where they fit, and the Committee can then 
enter into discussions with individual NGOs to get them 
interested in underserved aspects of the program. It is 
advisable to ask all NGOs to make a commitment to 
work within or through the national Prevention of 
Blindness Committee, and in turn to ask the Ministry 
of Health to be flexible without being indecisive when 
dealing with NGOs. In other words, partnership be- 
tween the Ministry and NGOs should be based on 
mutual trust and understanding. 

• Acquiring suitable managers. The whole concept of 
setting up a managing organ for the national eye-care 
program relies on the availability of able managers. In 
general terms, the managers of an eye-care program 


Management of an Eye-Care Program 145 

managed through a national Prevention of Blindness 
Committee consist of the Committee chairman and the 
Committee secretary. In some cases, a program coor- 
dinator is appointed to strengthen the link between the 
Committee and the actual program. But generally, the 
key national managers are the chairman and the 
secretary. It is imperative that the Ministry of Health 
appoint not just a senior officer to chair the national 
Prevention of Blindness Committee, but that the of- 
ficer so appointed be one who has a personal interest 
in the Committee and the program and who would 
therefore be committed to this duty. 

Establishing contacts with the program. Once the Com- 
mittee has been established and is functioning, it is 
necessary for it to set up administrative procedures 
which link it with the rest of the program. One ad- 
ministrative system is a subcommittee, or a number of 
them, depending on the circumstances of the country 
concerned. The functions of these subcommittees must 
be clearly stated, otherwise the central Committee may 
not benefit from their input. The subcommittees 
should, whenever possible, be represented at the cen- 
tral Committee. Requiring subcommittees merely to 
submit minutes of their deliberations is not adequate. 

Attracting sufficient resources. No program can func- 
tion without financial and human resources. One of 
the first challenges that must be overcome in 
establishing a management structure for a national eye- 
care program is the need to attract sufficient resources 
required both by the program as a whole and by its 
administrative machinery. Governments have proved in- 
valuable in supplying trained medical personnel for the 
program, and in attaching these to the program at their 
own expense. NGOs have proved invaluable in providing 
such resources as vehicles for the program and finances 
to “lubricate” not just the administration of the pro- 
gram but perhaps even the entire program. Each in- 
tending country must find ways of taking advantage 
of these resources as best as it can. 


146 Plenary Session III— Sustainable Manpower Development 

CONCLUSIONS 


This paper has set out broad practical steps I believe are necessary 
in the establishment of a managing organ for a national eye-care 
program. I believe that the best managing organ so far demonstrated 
is the national Prevention of Blindness Committee. Such a Com- 
mittee should be provided with sufficient power and endowed with 
adequate administrative procedures. Only then will a national 
Prevention of Blindness Committee become a reliable management 
organ. I also believe that all countries should establish such a Com- 
mittee and that those who already have one should strive to im- 
prove their Committee so that it will be able to meet new challenges. 


PART 



PLENARY SESSION IV 

New 

Developments in 
the Control of 
Major Causes 
of Blindness 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 



1 


Developments in the Control 
of Cataract: Epidemiology 
and Clinical Research 

Prof. Gordon J. Johnson 
INCIDENCE 

From random population-based surveys, we now have quite good 
figures in a number of countries for the prevalence of blindness 
or severe visual impairment caused by blindness — that is, the 
numbers requiring attention at the time of the survey. For exam- 
ple, in the Gambia there were 5,500 blind people out of a popula- 
tion of approximately 800,000; this is the equivalent of about 7,000 
blind persons per 1 million in Africa. 1 

But how many new cases of blinding cataract are being added 
to the pool each year? What is the incidence of blinding cataract. 
Until recently, there was virtually no information regarding the rate 
at which new cases were occurring, and without such information, 
it is difficult to project the future requirements for cataract services 
in any given community. There are two ways of arriving at such 
an estimate of incidence: by direct measurement and re-examination 
of the same sample of the population after an interval of time, and 
by calculation from age-specific prevalences. 

In Central India, Drs. Darwin Minassian and Vijay Mehra took 
a random sample from 19 communities of 1735 people age 30 and 
over in 1982. 2 In this sample 1655 people were at risk of going blind. 
They were reexamined four years later for evidence of blinding 
cataract, to give for the first time direct estimates of the incidence 
of blindness from cataract in each five-year age cohort. Assuming 
these communities are representative of India as a whole, they in- 
dicate that an estimated 3.8 million persons become blind in both 
eyes from cataract each year in India — a figure far higher than 
previously suspected. 

The City Eye Study in London has measured the incidence of 


149 


150 Plenary Session IV— Developments in Control of Blindness 

new lens opacities and visual reduction from cataract in a cohort 
of 1029 volunteers around retirement age. This was compared with 
the incidence calculated from the formulas applied to the Fram- 
ingham Eye Study by Podgor, Leske, and Ederer 3 and was found 
to be twice as great (Bamford N, Ehrlich D, not yet published)! 

Another formula has been developed which takes into account 
loss of people from the study by differential mortality. 4 This new 
formula gives figures much closer to the directly measured incidence 
in London. Further work in this area is required. It would clearly 
be of great value, saving time and money, if reliable incidence data 
could be derived from well-conducted prevalence surveys. 

In Western countries we have an idea of the number of cataracts 
being operated on each year by the health services, but we do not 
know how many remain undetected and untreated, and we have lit- 
tle reliable data on prevalence and incidence. In one sample of a pilot 
study examining all those over 65 years of age in two group practice 
lists within the inner city in London, 12 percent had cataract that 
was suitable for surgery and had not yet been referred (Wormald 
R, Courtney P, not yet published). Much untreated cataract was 
similarly found in a rural Appalachian community in the USA. 5 


CAUSATION 

The results of three major case-controlled studies in New Delhi, 6 
Boston, 7 and Parma 8 in Italy into the aetiology of cataract have either 
recently been published or are just becoming available. In these studies 
the “cases” are usually people presenting to the hospital with cataract. 
The “controls” are people of the same age and background who have 
other conditions. 

From these studies a large number of factors — personal, 
behavioral, nutritional, biochemical — have been found to be 
associated with cataract. However, there are variable results and in- 
consistencies between the studies, and the relative risks are frequently 
low, of the order of 1.2-1 .6. It is not at all clear whether they have 
any causative significance. 

Four associations with cataract stand out fairly consistently: 

1. Low socioeconomic status and low education; 

2. Low height, weight, and body mass index, associated especially 
with nuclear cataract; 


Cataract: Epidemiology and Clinical Research 151 

3. Diabetes; and 

4. Use of steroids associated with posterior-subcapsular cataracts. 

In Boston there were also biochemical changes which went along 
with poor nutrition, including low dietary intake of riboflavin, 
vitamins A, C, and E, and iron, niacin, thiamin, and albumin. The 
regular use of multivitamin supplements was protective. But associa- 
tions with nutritional variables apparently did not show up in Parma. 

Two recent publications have implicated cigarette smoking as a 
risk factor. In the City Eye Study in London there was a relative 
risk of 2.9 for current heavy smokers and nuclear cataract. 9 From 
Baltimore came a report of a significantly increased risk of pure 
nuclear cataract and cigarette smoking in fishermen. 10 

There is further evidence of dehydrational crises being a risk factor 
in India, this time in a longitudinal study. From the same cohort 
study there has now emerged a 2:33 greater hazard of death in pa- 
tients with cataract. This does not occur with other causes of visual 
loss, and is still present with even minor degrees of lens opacity, 
without significant visual loss (Minassian DC, Mehra V, not yet 
published). 

There have been previous suggestions, in four papers from the 
United States and one from Britain, of an increased mortality 
associated with surgery for cataract. 11 ' 121314 The observation from 
Britain that there was no correlation between the age of patients at 
surgery and the interval until death suggested that the development 
of cataract reflects an aging process in the patient as a whole. 15 The 
study from India, however, is the first evidence that cataract per se 
is associated with raised mortality; this lends further weight to the 
presumption that the excess of cataract cases in India is related to 
major disturbances in general health status. 


Long-Term Follow-Up of Cataract Surgery 

For around 80 years, and with the investment of millions of rupees, 
pounds, and dollars, eye camps have been conducted on the Indian 
subcontinent. There has been no thorough evaluation of the long- 
term results in terms of the visual acuity, rate of complications, or 
quality of life. The success rate is usually given in terms of what 
is seen at the six-weeks postoperative visit. Because of the skills and 
persistence of the medical assistants working on this project, Vi jay 


152 Plenary Session IV— Developments in Control of Blindness 

Mehra and Angela Reidy have been able to achieve a 100 percent 
follow-up rate at one year, comparing rural eye-camp surgery with 
surgery in a base hospital by the same surgeon. The pooled eye-camp 
sites had a very slightly increased rate of poor vision, but the dif- 
ference was not significant. 16 

The worst results were seen when someone came for a short period 
to help at an eye camp. The good results, comparable to those in 
the hospital, were only achieved by an ophthalmologist experienced 
in rural surgery. 

More follow-up data are required, both from the developing and 
the industrialized world, if possible for periods longer than one year. 


Clinical Trials of Different Types of Surgery 

A workshop organized by the I APB and the National Eye Institute 
(Bethesda, Maryland) in Kathmandu, Nepal, in November 1989 
looked at “operations research in the control of cataract blindness 
in the developing world.” At the end of the meeting the delegates 
were asked to vote on what they thought were the most important 
subjects for operations research, in order of priority. The first two 
topics received substantially more votes than the later ones: 

1. Conduct randomized controlled clinical trials in developing 
countries using experienced surgeons and techniques ap- 
propriate to the setting to evaluate extracapsular surgery with 
IOLs and intracapsular surgery with eyeglasses, including 
evaluation of complication rates, patient satisfaction, time, 
and cost. 

2. Identify the barriers that stop patients from obtaining surgery. 

3. Gather additional data on prevalence and incidence. 

4. Evaluate the alternatives to current delivery systems, including 
the use of outpatient surgery in Cataract-Free Zones in Latin 
America, eye camps in Asia, and ophthalmic assistants to per- 
form surgery in Africa. 

5. Determine what constitutes patient satisfaction and why some 
people do not wear their aphakic glasses. 

6. Determine what the community believes is needed in the field 
of prevention of blindness. 


Cataract: Epidemiology and Clinical Research 153 

Although we know that excellent results can be obtained with 
extracapsular surgery and IOLs under optimal conditions, it is 
necessary to know (before we can make recommendations for 
widespread application) what the comparative blinding complica- 
tion rates and costs are between IOL surgery and routine ICCE in 
typical situations in developing countries. 

Preparations are being made at present for randomized clinical 
trials in two suitable locations. It is essential that the patients can 
be recalled for follow-up at one year, and ideally for at least three 
years to include many of the cases of capsular thickening and corneal 
decompensation. 

There has also been a recent initiative from Norway with Dr. 
David Apple in the United States for a controlled trial of intracap- 
sular cataract extraction, with and without insertion of an anterior 
chamber (AC) lens. The new generation of AC lenses are thought 
to cause many fewer complications than the earlier models. It cer- 
tainly would be an easier technique in most situations than posterior 
chamber implantation, and would not require the same magnifica- 
tion or use of irrigating fluids. 


CONCLUSION 

In summary, present work is addressing the important questions of: 

1. How many people go blind each year from cataract? 

2. What causes lens opacity and how may we prevent its develop- 
ment into a blinding lesion? 

3. What is the safest and most cost-effective way of providing 
patients with acceptable cataract surgery? 

I hope in four years time we will have more information on these 
important questions. 


REFERENCES 

1. Faal H, Minassian D, Sowa S, Foster A. National Survey of 
blindness and low vision in the Gambia: Results. Brit J 
Ophthalmol 1989;73:82-7. 

2. Minassian DC, Mehra V. 3.8 million blinded by cataract each 


154 Plenary Session IV— Developments in Control of Blindness 


year: projections from the first epidemiological study of incidence 
of cataract blindness in India. Brit J Ophthalmol 1990;74:341-3. 

3. Podgor MJ, Leske MC, Ederer E Incidence estimates for lens 
changes, macular changes, open angle glaucoma and diabetic 
retinopathy. Am J Epidemiol 1983;118:206-12. 

4. Podgor MJ, Leske MC. Estimating incidence from age-specific 
prevalence for irreversible diseases with differential mortality. 
Statistics in Medicine 1986;5:573-8. 

5. Dana MR, Tielsch JM, Enger C, et al. The prevalence and causes 
of visual impairment in a rural Appalachian community. In- 
vest Ophthalmol Vis Sci 1989; 30(3-suppl):495. 

6. Mohan M, Sperduto RD, Angra SK, et al. India-US case con- 
trol study of age-related cataracts. Arch Ophthalmol 
1989;107:670-6. 

7. Leske MC, Chylack LT, Wu SY, et al. The lens opacities case- 
control study: 1. Nutritional and other risk factors. Invest 
Ophthalmol Vis Sci 1990;31(4-suppl):374. 

8. Maraini G, Pasquini P, Sperduto RD, et al. Risk factors for cor- 
tical, nuclear and posterior subcapsular cataracts. Invest 
Ophthalmol Vis Sci 1990;31(4-suppl):374. 

9. Flaye DE, Sullivan KN, Cullinan TR, et al. Cataracts and 
cigarette smoking. Eye 1989; 3:379-84. 

10. West S, Munoz B, Emmett EA, Taylor HR. Cigarette smok- 
ing and risk of nuclear cataracts. Arch Ophthalmol 1989; 107: 
1166-9. 

11. Rogot E, Goldberg ID, Goldstein H. Survivorship and causes 
of death among the blind. J Chronic Dis 1966;19:179-97. 

12. Hirsch RP, Schwartz B. Increased mortality among elderly 
patients undergoing cataract extraction. Arch Ophthalmol 
1983;101:1034-7. 

13. Podgor MJ, Cassel GH, Hammel WB. Lens changes and sur- 
vival in a population-based study. N Engl J Med 1985;3 13: 
1438-44. 

14. Benson WH, Farber ME, Caplan RJ. Increased mortality rates 
after cataract surgery. Ophthalmology 1988;95:1288-92. 

15. Gilbert CE, Harcourt B. Survival of patients following second 
eye cataract extraction. Trans Ophthalmol Soc UK 1986; 
105:447-52. 


Cataract : Epidemiology and Clinical Research 155 

16. Reidy A, Mehra V, Minassian D, Mahashabde S. Outcome of 
cataract surgery in Central India: a longitudinal follow-up study. 
Brit J Ophthalmol 1991;75:102-10. 


ACKNOWLEDGEMENTS 

I wish to thank: Darwin Minassian, Parul Courtney, Vijay Mehra 
(Raipur, India), Angela Reidy, Richard Wormald, and Neil Bamford. 



2 


Economic Aspects of Cataract Blindness 

Dr. Michael F Drummond 

INTRODUCTION 

It is important to study the economic aspects of health-care pro- 
grams because resources are scarce. They are relatively limited when 
compared with the potential uses to which they can be put. This 
means that when a given resource is used in a particular activity, 
the community forgoes the opportunity to use the same resource 
in its best alternative use. Economists define the (opportunity) cost 
of a resource as the benefits that it would have generated in its best 
alternative use. Therefore, the evaluation of health-care programs 
requires assessment of both costs and benefits. The most efficient 
allocation of resources would be the one that maximizes the total 
benefits to the community from the resources at its disposal. 

In considering cataract blindness, an efficient allocation of 
resources would require that: 

• the appropriate amounts of resources are devoted to cataract 
surgery when compared with those devoted to other health- 
care programs; and 

• the resources devoted to cataract surgery are used in the best 
possible way. 

The objective of this paper is to explore these issues using ex- 
amples from both the developed and developing world. 


EVIDENCE FROM THE DEVELOPED WORLD 
Value for Money from Cataract Surgery 

In a recent paper, Drummond 1 assessed the relative value of money 
from cataract extraction when compared with other health-care pro- 
grams in order to determine the relative priority that the operation 
should receive. In the developed world it is becoming increasingly 


157 


158 Plenary Session IV— Developments in Control of Blindness 

popular to calculate the cost per quality-adjusted-life-year (QALY) 
gained from different health-care programs. 2 - 3 The logic is that a 
relatively higher priority should be given to interventions that gen- 
erate improvements in health at a relatively lower cost (see Table 1). 

Drummond made estimates of the cost per QALY of cataract 
extraction by using cost data obtained in an earlier study 4 and by 
making several additional assumptions. If it were assumed that 
cataract operations were performed on individuals with approx- 
imately 10 years life expectancy, and that this would improve their 
quality of life during their remaining lifetime, the costs (in 1989-90 
prices) of the initial treatment and 10 years after care would be 
£21,200. Based on calculations made for the health state “being blind 
or deaf or not able to speak,” Drummond calculated that the quality 
of life with advanced lens opacity would be approximately 0.6 (better 
than being completely blind) and that the quality of life after cataract 
surgery would be 0.9 (lower than completely healthy), this would 
represent a quality gain of 0.3 in each of the 10 years. Calculating 
the incremental cost per QALY would give a figure, in 1989-90 
prices, of approximately £2750 per QALY gained (discounting costs 
and benefits occurring in the future at 5 percent per year). This 
compares relatively favorably with many of the interventions shown 


TABLE 1. 

Cost Per QALY Gained for Selected Health Care Interventions 
(£, 1989-90 Prices) 


GP advice to stop smoking 

260 

Hip replacement 

1,140 

CABG for severe angina LMD 

1,590 

GP control of total serum cholesterol 

2,600 

Breast cancer screening 

5,340 

CABG for mild angina 2VD 

19,250 

Hospital haemodialysis 

21,500 


Adapted from Williams (1985). 


Economic Aspects of Cataract Blindness 159 

in Table 1, and several more pessimistic assumptions could be made 
before cataract extraction were to become poor value for money. 


Clearing the Cataract Backlog in the United Kingdom 

Despite the apparent good value for money from cataract extrac- 
tion in the United Kingdom, there are still significant waiting times 
for treatment. Thus, the cataract backlog is not only a phenomenon 
of the developing world. Drummond and Yates 5 estimated that there 
were 74,000 patients in total on ophthalmology hospital waiting lists 
in England in the first quarter of 1989, of which approximately 75 
percent were cataract cases. Moreover, the number of ophthalmology 
cases waiting over one year was 12,500 (see Figure 1). Whereas in 
1976 ophthalmology lists represented only 6 percent of all patients 
waiting for treatment in England, in 1989 they represented around 
10 percent of all patients. 

In examining the reasons for the backlog, Drummond and Yates 



Year 

Source: SBH 203 and KH07 half yearly returns 


Figure 1. Ophthalmology in-patient waiting list — England 1975 to 1989. 


160 Plenary Session IV— Developments in Control of Blindness 

point out that there is currently a shortfall of around 225 consul- 
tant ophthalmologists in England as defined by the College of 
Ophthalmologists’ own standard. There may also be an imbalance 
on the use of resources, in that there may be a lack of operating 
theater time, trained theater staff, anesthetists, or beds in some 
localities where surgeons are available. On the other hand, they also 
point to possible inefficiencies in the use of resources. For exam- 
ple, it can be seen from Figure 2 that there are wide variations in 
one English region in the number of operations per ophthalmology 
firm per year. The variations are only partly explained by the 
availability of more junior surgeons (senior registrars in Figure 2). 
Perhaps even more worrisome is the fact that the average number 


10 - 



Up to 0 100 200 300 400 500 600 


EH Number of Operations E2 Senior Registrar Support 

Source: HAA 

Figure 2. All operations by consultant firm (cold, day-case, and emergency). 
34 surgeons in one region 1985. 


Economic Aspects of Cataract Blindness 161 

of operations per firm (275) is below the guideline suggested by 
the College of Ophthalmologists (between 320 and 400 per year). 
The operating rates are also far below those of surgeons in other 
clinical specialties. 

Drummond and Yates also point to variations in the number 
of day-case admissions (see Figure 3). This has been shown to be 
more cost-effective than inpatient care in a developed country 
setting. 6 Of course, such aggregate data do not prove that resources 
are being used ineffectively. However, they do suggest that further 
inquiries are justified. 

Finally, Drummond and Yates consider various ways of clear- 
ing the backlog. One particularly interesting local initiative in the 
United Kingdom is “Operation Cataract” because it draws its in- 
spiration from the eye camps that have been established in the 
developing world. 7 By using a local hotel rather than hospital beds, 
which were in short supply, about 100 patients were operated on 
in a five-day period. Using the hotel increased bed capacity in the 
ward from 115 nights to over 400 nights. Overall, the scheme 
represented an intermediate stage between day-case procedures and 
traditional inpatient treatment. 

In summary, evidence from the United Kingdom suggests that 
not enough resources are devoted to cataract surgery when com- 
pared with other health-care interventions. Furthermore, the 


20 



Percent of Day-cases 

Source: Health Service Indicators 


Figure 3. Percent day admissions for ophthalmology 1987 (153 displayed). 


162 Plenary Session IV— Developments in Control of Blindness 

resources devoted may not be being used in the best possible way. 
Further analysis is required to assess whether day-case surgery and 
local initiatives like “Operation Cataract” represent a more cost- 
effective use of resources. 


EVIDENCE FROM THE DEVELOPING WORLD 

Most of the data presented in this section are taken from a report 
on a visit to Aravind Eye Hospital in southern India, sponsored 
by the National Eye Institute. 8 The purpose of the visit was to col- 
lect preliminary data on two aspects of the economics of cataract, 
including the following questions: What is the economic impact 
of blindness on patients and their families, and how does this af- 
fect willingness to attend for surgery? Is extracapsular extraction 
with an intraocular lens (ECCE-IOL) a feasible and cost-effective 
alternative to intracapsular extraction (ICCE) in the developing 
world? 

The first issue therefore relates to need for cataract surgery and 
hence the resources that should be devoted to it. The second is one 
of the most important current issues relating to the use of resources 
devoted to cataract surgery. 


Economic Impact of Cataract Blindness and its 
Relationship to Attendance for Surgery 

This was investigated through interviews with patients attending the 
outpatient clinic (in the paying section of the hospital) and with 
people in two villages, Chittaloti and Karayanpatti, in the Kallupatti 
Block of Madurai District approximately 50 kilometers from the 
city. The patients in the paying section were virtually all accom- 
panied by relatives who, in general, paid for the surgery. The per- 
sons interviewed in the villages were a mixture of past cataract pa- 
tients and those being examined for the first time. Most of these 
had been identified by health workers from ASSEFA, a voluntary 
organization working in the area. Around 50 persons in all were 
interviewed. 

Although the paying patient generally had more resources, a 
common feature for all was the dependence upon the family struc- 
ture for their economic survival. In particular, the older patients 
were often living with or near their children, who provided them 


Economic Aspects of Cataract Blindness 163 

with food or money. Many of the patients in the paying section 
had been severely visually impaired for a year or more. They had 
finally presented themselves for surgery when their relatives had 
saved enough money and could spare the time off work to bring 
them. Since surgery was normally performed the next day and in- 
volved an inpatient stay of five days, the financial sacrifice by the 
accompanying relative could be substantial. Although the relatives 
of paying patients were encouraged to stay in the hospital to reduce 
nursing costs, those of the free patients were ofocouraged to reduce 
the total financial burden on the family. However, the hospital was 
not always successful in convincing people to come in for surgery 
alone because of strong family ties. 

The charges for cataract extraction ranged from Rs. 550 ($33) 
to Rs. 1,000 ($60) depending on the quality of the hospital room 
(January 1990 prices). The additional charge for extracapsular ex- 
traction with a posterior chamber intraocular lens was Rs. 1,200 
($72). 

Wage rates in the rural economy were Rs. 7-10 ($0.42-0.60) per 
day for men and Rs. 4-7 ($0.24-0.42) per day for women, with most 
people working around 200 days per year. As one would expect, 
wage rates in the city were generally higher, but with a wide range. 
A hospital cleaner would make about Rs. 10 per day ($14.50 per 
month), whereas one bank employee accompanying his mother to 
hospital was earning Rs. 3,000 ($180) per month. Old age pension, 
available only to those with no living relatives to support them, pays 
Rs. 50 ($3) per month. Therefore, for many people, not only is the 
cost of surgery a barrier, but transportation to the hospital (Rs.20 
for a round trip from some villages) and loss of earnings can also 
be problematic. This finding is confirmed by the recent study on 
the social determinants of cataract surgery in southern India. 9 

The level of functioning of individuals varied with their level of 
disability and role in the community. Those identified in need of 
immediate surgery had vision less than 3/60 in the worst eye. 
Although most reached the village health post unaccompanied, few 
could count fingers. Other people seen had vision better than 3/60 
but less than 6/18, although these people were having difficulty see- 
ing properly they were not given priority for surgery. 

There is little doubt that blindness from cataract imposed an 
economic and social burden on the affected individual and their 
families. The extent to which this imposed an economic burden on 
the community as a whole by reducing the potential work force was 


164 Plenary Session IV— Developments in Control of Blindness 

harder to assess in this small survey. For example, if the economy 
were not operating at near full employment, the lack of work 
capacity from the cataract blind would not be very significant. 
However, it is known from larger surveys 10 that a significant pro- 
portion (55 percent) of Indians in the 50-59 age group have a 
cataract in either eye. Also, from the small ad hoc survey under- 
taken here, there were surprisingly high labor participation rates 
among women and those over 60. In addition, in rural subsistence 
economies, there are peak times of the year (e.g. harvests) where 
all available manpower is required. However, this aspect would re- 
quire further study. 

In summary, all the patients needing surgery were at near sub- 
sistence level and required someone else to support them. Unless 
they lived with or near their children, they would be unlikely to have 
enough resources to pay for surgery. In the villages the household 
income of cataract blind people living with their spouse could be 
less than $0.50 per day. For these individuals the cost of food and 
transportation for their hospitalization would be a major financial 
barrier. In addition, the spouse would be unable to give up work 
in order to accompany them to hospital. Unless the person could 
be persuaded to come alone this would be yet another barrier to 
surgery. Cataract blindness was therefore an economic burden on 
the family and probably also to society at large. 


Cost-effectiveness of ICCE and ECCE-IOL 

Now that extracapsular cataract extraction with a posterior chamber 
intraocular lens (ECCE-IOL) has established itself as the procedure 
of choice in the developed world, there are some who argue that 
the same approach should be encouraged in the developing world. 
Advocates argue that the superior vision afforded by ECCE-IOL, 
while beneficial in its own right, might also encourage more pa- 
tients to come for surgery. In addition, they argue that in some set- 
tings patients are now demanding ECCE-IOL. 

On the other hand, concerns have been raised about the higher 
costs of ECCE-IOL as compared with ICCE, the increased need 
for capsulotomies, and possible other complications. 11 Aravind pro- 
vided a good setting to explore these issues further because it under- 
takes both ECCE-IOL and ICCE with good results and is generally 
well-organized. It also operates in a region where there is a signifi- 
cant cataract backlog and where choices in the allocation of scarce 


Economic Aspects of Cataract Blindness 165 

resources are particularly stark. From the economic viewpoint, the 
choice between the two procedures depends on comparative costs 
and quality of outcome. 

It was stated above that the current charge at Aravind for a basic 
ICCE with the lowest quality hospital room is $33. Because some 
of the funds from the paying patients help to subsidize the care of 
the free patients, the true cost of the operation is probably less than 
$30. The basic aphakic spectacles, which are given free to those who 
cannot pay, cost Rs. 50 ($3), although more sophisticated spectacles 
can cost as much as Rs. 1,000 ($60). Therefore, a fair cost estimate 
for the whole procedure is $30, including the provision of one pair 
of basic spectacles. 

The incremental charge for ECCE-IOL at Aravind was Rs. 1,200 
($72), although again this may not necessarily reflect true cost. There 
were a number of additional costs: increased surgical time, extra 
tests and consumables, and more sophisticated equipment. These 
are discussed in turn. 

The time taken for cataract extraction varied greatly between 
surgeons. Most of the surgeons at Aravind were highly skilled in 
the procedure and would expect to perform an ICCE in six to seven 
minutes. It was estimated that implanting an IOL takes about an 
extra five minutes. No significant additional training would be 
necessary at Aravind because 50 percent of the surgeons can already 
perform ECCE-IOL. 

In Aravind the extra time taken for ECCE-IOL, although small, 
would seriously reduce surgical throughput, because this is already 
extremely high in relation to the level of resources. Around 100 ex- 
tractions are performed each day using 4 operating theaters and 
the average surgeon performs 1,400 operations per year. However, 
the average for India is only 130 operations per ophthalmologist, 
although all do not operate. Therefore, it is possible that in other 
less-efficient centers the increased time to perform ECCE-IOL could 
be absorbed with no loss in overall surgical throughput. In Ara- 
vind, throughput could not be maintained without extra resources. 

A number of extra tests and consumables are required for ECCE- 
IOL. Concentrating on consumables, the main items are the lens 
itself and the visco-elastic agent. At the time of the study, Aravind 
was able to buy modern posterior chamber lenses for Rs. 300 ($18), 
although the general market price in India is currently Rs. 600 ($36). 
The visco-elastic agent costs $120 per packet, although the use of 


166 Plenary Session IV— Developments in Control of Blindness 

this was kept to a minimum (around 5 percent of patients) by in- 
jecting air during the operation. 

The expected incremental cost for consumables was therefore 
$24 based on the assumption that a plentiful supply of cheap lenses 
could be maintained. (Like many other hospitals in the developing 
world, Aravind has a number of lenses donated. However, this has 
been ignored because such donations would not cope with a major 
switch to ECCE-IOL and, in any case, there is still a real resource 
cost for donated lenses. That is, the donations could be used for 
something else.) 

The main additional items of equipment were the operating 
microscope and the YAG laser for performing capsulotomies. 
(Although capsulotomies can be performed surgically it has been 
assumed that this would not be feasible without seriously affect- 
ing the capability to reduce the cataract backlog.) 

Aravind is equipped with operating microscopes in all four 
theaters. These cost Rs. 40,000 ($2,400), and are manufactured 
locally. On the assumption that these last at least five years, the 
incremental cost per operation is insignificant given Aravind’s 
throughput. 

YAG lasers are not currently manufactured locally and cost Rs. 
660,000 ($40,000). Aravind had two machines, one bought for 
$30,000 and the other (a demonstration model) bought for $8,000. 
In addition, the annual maintenance contract was Rs. 25,000 ($1,500) 
per machine. Assuming a 10-year life and a discount rate of 10 per- 
cent per year, the equivalent annual cost per laser, including 
maintenance, was approximately Rs. 100,000 ($6,000). The addi- 
tional cost per patient depends critically on the number of cap- 
sulotomies that are required and the number of lasers needed to 
perform them. 

At the time of the study, Aravind was performing around 40,000 
operations per year. Conservatively, one would expect 25-30 per- 
cent of patients having ECCE-IOL to require a capsulotomy within 
five years. Therefore, if Aravind were to switch completely to ECCE- 
IOL it would eventually need to perform about five capsulotomies 
a year for every 100 patients having an extraction (or 2,000 per year). 
This level is within the capability of the existing lasers, being about 
20 per week per machine. On a per patient basis this would imply 
an incremental cost of $3.00 per extraction to allow for capsulotomy. 
(This ignores the additional costs falling on the patients, which may 
be $0.50-$1.00 for transportation.) 


Economic Aspects of Cataract Blindness 167 

In total the additional cost of ECCE-IOL is likely to be $27, 
comprising $24 for consumables and $3 for equipment. In other 
words ECCE-IOL is approximately double the cost of ICCE. In 
addition, real resource restrictions at Aravind would mean that the 
number of extractions in a year would fall because of the extra 
surgical time needed for ECCE-IOL. However, the main target in 
reducing cost would be consumables, the major component of which 
is the lens itself. 

Nobody denies that superior vision is obtained with ECCE-IOL 
in the developed world. However, less is known about outcomes in 
a developing country setting and the impact that improved vision 
has on the quality of life and functioning of the patient. The rates 
of complications for ICCE and ECCE-IOL in the developing world 
could only be accurately established through a clinical trial. However, 
the informal impression was that outcomes were good and com- 
plication rates low for both procedures at Aravind. Javitt et al. 12 
found that 85 percent of the patients they surveyed achieved 
postoperative visual acuity of 6/36 or better. 

The other aspect of quality of outcome is the satisfaction ex- 
pressed by the patient. Ideally, a rigorous survey is required, although 
preliminary data already exist in Aravind. First, approximately 45 
percent of the paying patients (or their relatives) in Aravind opt 
for ECCE-IOL when the choices (and costs) are explained to them. 
The percentage was even higher (70 percent) in the sister hospital. 
Although records were not analyzed, hospital staff felt that those 
opting for the more expensive procedure were those whose jobs re- 
quired good vision, truck drivers, for example. This view was sup- 
ported by the report that a major company employing drivers had 
requested ECCE-IOL on their behalf. 

On the other hand, during the village visits a high proportion 
of operated patients (over 90 percent) were still wearing their aphakic 
spectacles. It was suggested, however, that this was partly due to 
the active involvement of ASSEFA in the villages concerned. Most 
patients could see reasonably well with their spectacles, although 
a minority (less than 10 percent) did complain of vision problems, 
and probably needed new spectacles. No data were collected on 
whether some patients had been issued with more than one pair. 
However, at $3 per pair a considerable number of re-issues would 
be required to reduce the difference in cost between ICCE and 
ECCE-IOL. 

In summary, the study in Aravind suggested that cataract blind- 


168 Plenary Session IV— Developments in Control of Blindness 

ness was a source of economic burden to patients and their families. 
Although overall the program of cataract extraction was operating 
efficiently, a number of issues remained unresolved, most notably 
whether to increase the number of extracapsular cataract extrac- 
tions with intraocular lens implant. 


CONCLUSIONS: SUGGESTIONS FOR FURTHER RESEARCH 

A number of research initiatives for improving the efficiency and 
effectiveness of cataract care in developing countries have been 
previously identified. 13 These were projects to: 

1. Prepare the effectiveness of various methods of identifying 
cataract-blind people within a community and, through the 
reduction of psychosocial and economic barriers, motivate 
them to seek surgery; 14 

2. Compare alternatives for improving access to cataract surgery, 
such as eye camps or the establishment of temporary satellite 
hospitals; 

3. Evaluate alternative forms of minimum level ophthalmic 
surgical facilities in regions that are currently underserved; 

4. Improve operating room efficiency; 

5. Determine ways of reducing the postoperative stay follow- 
ing cataract surgery; 

6. Increase the number of ophthalmic personnel trained to per- 
form cataract surgery in underserved areas. 

A number of other potential research questions could be added 
based on the discussion above, including the following: 

1. How does cataract surgery improve the economic well-being 
and quality of life of patients? (This relates both to the 
developed and developing world.) 

2. Does the implantation of intraocular lenses increase the up- 
take for cataract surgery in developing countries because of 
the superior sight obtained? 

3. What are the nature and relative rates of complications for 
ECCE-IOL and ICCE in developing countries? 

4. What is the likely cost of intraocular lenses produced in the 
developing world? 


Economic Aspects of Cataract Blindness 169 

Once these questions have been answered, it will be possible to 
assess the appropriateness of the level of resources devoted to 
cataract surgery in developing countries and the most cost-effective 
form of treatment. 


REFERENCES 

1. Drummond MF. Economic aspects of cataract. Ophthalmology 
1988;95(8):1, 147-53. 

2. Williams AH. Economics of coronary artery bypass grafting. 
Brit Med J 1985;291:326-32. 

3. Torrance GW, Zipursky AA. Cost-effectiveness of antepartum 
prevention of Rh immunization. Clinics in Perinatology 
1984;11:267-81. 

4. Davies LM, Drummond MF, Woodward EG, Buckley RJ. A 
cost-effectiveness comparison of the intraocular lens and the 
cataract lens in aphakia. Trans Ophthalmol Soc UK 
1986;105:304-313. 

5. Drummond MF, Yates JM. Clearing the cataract backlog in a 
(not so) developing country. Paper delivered at the Annual Con- 
gress of the College of Ophthalmologists. Harrogate, April 1990. 

6. Wall R, Birch S, McQuillin M. Economic evaluation of alter- 
native programs of reduced-stay senile cataract surgery. 
Hamilton (Ont.), Centre for Health Economics and Policy 
Analysis Working Paper 90-2, McMaster Health Sciences Cen- 
tre, 1990. 

7. Thomas HF, Darvell RHJ, Hicks C. Operation cataract: a means 
of reducing waiting lists for cataract operations. Brit Med J 
1987;299:961-96. 

8. Drummond MF. Economic aspects of cataract in Southern In- 
dia. Report on a visit to Aravind Eye Hospital. 1990 Mimeo. 

9. Brilliant G, Lepkowski J, Zurita B, Thulasiraj RD, et al. Social 
determinants of cataract surgery utilization in South India. 1989 
Mimeo. 

10. Lepkowski JM, Zurita B, Brilliant GE, Thulasiraj RD, et al. The 
epidemiology of cataract in South India. 1989 Mimeo. 

11. Kupfer C. Editorial. IAPB News (No. 12) August 1989. 


170 Plenary Session IV— Developments in Control of Blindness 


12. Javitt J, Venkatas wamy G, Sommer A. The economic and social 
aspect of restoring sight. In P. Henkind (ed.) ACTA: 24th 
International Congress of Ophthalmology. New York, J.B. 
Lippincott; 1983. 

13. Helen Keller International. To Restore Sight: the Global Con- 
quest of Cataract Blindness. New York, Helen Keller Interna- 
tional; 1986. 

14. Ellwein LB, Lepkowski JM, Thulasiraj RD, Brilliant GE, et al. 
The cost-effectiveness of strategies to reduce barriers to cataract 
surgery. Internat Ophthalmol 1991;15:175-83. 


ACKNOWLEDGEMENTS 

I am grateful to Dr. Venkataswamy, Mr. Thulasiraj, and their staff 
for the warm hospitality and extensive cooperation given during 
the visit to Aravind and to the National Eye Institute for financial 
support. 


Hi/ 2-333 
. u /233 



3 


Update: Xerophthalmia, Keratomalacia, 
and Child Mortality including Measles 

Dr. Barbara A. Underwood 

An effort was made recently to reevaluate the global magnitude of 
the problem of childhood blindness. 1 The consensus of those 
gathered in London was that there are an estimated 1.5 (± 0.5) 
million blind children (less than 3/60) under 16 years of age in to- 
day’s world and another 500,000 are visually handicapped to the 
extent of requiring rehabilitation services (between 3-6/60). Of the 
500,000 blind, 70 percent (350,000) are probably due to vitamin A 
deficiency. About twice as many (700,000) annually are thought to 
have active corneal involvement, and about tenfold more (6-7 
million) are believed to have milder forms of clinical deficiency, i.e., 
xerophthalmia. 

Subclinical, or marginal vitamin A depletion to the extent of 
having adverse physiological consequences affects an unknown 
multiple of this number. Some recent studies suggest that in some 
populations where dietary intake is documented to be chronically 
inadequate, 50-60 percent of the preschool-age children may be 
vulnerable to the morbidity and mortality risks of an inadequate 
vitamin A status. It is obvious that vitamin A deficiency, both as 
an evident clinical problem and as a more difficult to detect 
subclinical problem, continues to be of public health significance. 
Based on the WHO assessment as of 1985, the more serious prob- 
lem is located primarily in Asia and Africa. 

Dr. Sommer and his colleagues in Indonesia focused attention 
on the health and survival consequences of vitamin A deficiency 
not only for children with xerophthalmia, but also those without 
clinical signs who reside in areas where the problem is endemic. They 
reported that child mortality could be reduced from 34 to an 
estimated 75 percent and their studies implied that morbidity, 
especially from diarrhea and respiratory infections, was reduced as 
well. These claims astounded much of the scientific community who 


171 


172 Plenary Session IV— Developments in Control of Blindness 

called for repetition of the studies using a masked, placebo- 
controlled design that was not possible in Indonesia due to govern- 
mental policy. 

A very recent randomized, masked, controlled study was reported 
from Tamil Nadu in southern India. 2 This study was not a repeat 
of the Indonesia work that used a six-monthly distribution of the 
high-dose vitamin A capsule. Instead, the Indian study provided 
vitamin A in a dosage equivalent to the recommended intake for 
preschool-age children, the level easily obtainable from food. It was 
implemented by trained, local community workers who delivered 
the vitamin directly into the mouth of children each week for one 
year. Remember that this was an amount of vitamin A easily avail- 
able through common local foods if it were incorporated into the 
family pot from which the children eat. The results confirmed the 
importance of an adequate vitamin A status for child survival in 
child populations where chronic malnutrition and vitamin A defi- 
ciency are highly prevalent. 

Providing a consistent supply of vitamin A at a level attainable 
through food reduced mortality risk by more than half and the ef- 
fect of the improvement in vitamin A nutriture was almost im- 
mediately evident. However, this study did not find an effect of the 
vitamin on reducing the risk of common morbidities, i.e., diarrhea 
and respiratory infections. These results emphasize that vitamin A 
supplements alone will not solve the health problems of children 
from these very deprived environments. Other public health and 
sanitation programs are equally important, and must be accom- 
panied by effective nutrition and health education that focus on 
improved environmental sanitation, personal hygiene, female literacy, 
and appropriate child feeding. 3 

Indeed, the study from Madurai emphasizes the importance of 
taking a long-term approach to solving the vitamin A deficiency 
problem in deprived societies and in utilizing community-based in- 
frastructures for implementation. The first need is to raise the 
awareness of professionals, such as those in this audience, national 
and local leaders, and community residents of the importance of 
the problem to child health and survival. Then to introduce 
throughout the local infrastructure appropriate nutrition and health 
education, emphasizing the use of available, culturally acceptable 
vitamin A-containing foods prepared suitable for young child diets. 

Past failures in approaches to nutrition education have been 
marked by use of methods and materials unrelated to the reality 


Update: Xerophthalmia 173 


of the situation confronted by those being “educated.” New ap- 
proaches are required that are based on understanding the local 
situation and the potential for building upon knowledge derived 
from the community to adapt behaviors in child feeding to those 
relevant to solving the problem of vitamin A deficiency. Although 
high-dose supplementation programs have their place in treatment 
schedules and in those rare circumstances where there is no recourse 
through food, emphasis needs to be placed on food as the solution 
because in so doing, one addresses in a sustainable manner the other 
common nutritional inadequacies as well. 

Measles is a devastating disease contributing to malnutrition 
and mortality in young children throughout the world, and in Africa 
it is a significant cause of blindness as well. This association be- 
tween measles and blindness in Africa is well recognized. As the 
WHO Expanded Program on Immunization (EPI) continues to in- 
crease coverage with measles vaccination, a substantial reduction 
in the measles-related deaths and blindness can be anticipated. Until 
this occurs, it is important particularly in Africa to have a clear 
understanding of the synergistic relationship to ocular health and 
survival between measles and vitamin A deficiency. 

Studies have made it clear that vitamin A therapy does not pre- 
vent measles keratitis, but there are studies that suggest it prevents 
these lesions from progressing to blindness. However, there have 
not been randomized, placebo-controlled prospective clinical field 
trials to quantify the role of vitamin A deficiency in measles-related 
blindness and mortality. As a consequence, the use of vitamin A 
in treatment programs was not stressed until recent years. Drs. 
Barclay, Foster, and Sommer 4 refocused our attention on this 
association through their hospital-based study in Tanzania that was 
reported in 1987. This study showed a protective effect against mor- 
tality, particularly among children under two years of age, of giv- 
ing two doses of 200,000 IU vitamin A one day apart. This led the 
WHO/EPI program later the same year to recommend routine use 
of vitamin A supplements for all children with measles in regions 
where vitamin A deficiency is a recognized problem and suggested 
that elsewhere “in countries where the fatality rate of measles is 1.0 
percent or higher that it would be sensible to provide vitamin A 
supplements to all children diagnosed with measles.” 5 

The effectiveness of vitamin A is best documented by hospital- 
based studies. Observational studies in Kinshasa, Zaire, 6 associated 
lower vitamin A levels with measles deaths during hospitalization 


174 Plenary Session IV— Developments in Control of Blindness 

and a very recently reported randomized, controlled trial in South 
Africa reported that the risk of death was reduced by half by giv- 
ing two doses on consecutive days of 200,000 IU vitamin A. 7 Accom- 
panying pneumonia, diarrhea, and croup symptoms were relieved 
faster as well. The authors recommended that all children with severe 
measles be given high doses of vitamin A because previous nutri- 
tional adequacy may not ensure against development of hyporet- 
inemia in severe measles. 

This recommendation seems highly appropriate for Africa. 
Measles in Asia, however, where equally high levels of hyporetinemia 
are reported and where clinical vitamin A deficiency is more preva- 
lent than in South Africa, is less severe in its irreversible ocular con- 
sequences. 8 9 It still is associated with mortality and blindness, 10 but 
the protective role of vitamin A needs additional clarification. 11 
Other risk factors such as the extent and kind of accompanying 
PEM may be an important explanation of the regional differences 
noted. 

In any case, any infection increased the need for vitamin A, and 
measles infections seems to exaggerate this demand even more. Thus, 
in areas where vitamin A deficiency is endemic, vitamin A sup- 
plementation along with measles treatment seems warranted. Again, 
however, equally important are programs that both prevent measles 
through vaccination and vitamin A deficiency through proper diet 
prior to the time children are at high risk of contracting measles. 
Of course, measles immunization programs alone will go far toward 
alleviating the problem of related blindness and mortality. These 
programs in areas where vitamin A deficiency is endemic poten- 
tially can also deliver the vitamin and the message that could relieve 
also the vitamin A-related mortality. 

The current generally held view on the relation of vitamin A 
deficiency and child health and survival recently was summarized 
in a statement by the Steering Committee of the International 
Vitamin A Consultative Group (IVACG). (A copy of the full state- 
ment is available for those interested. Write to the IVACG 
Secretariat, International Life Sciences Institute — Nutrition Foun- 
dation, 1126 Sixteenth St., N.W., Washington D.C. 20036 USA.) It 
is obvious that there is an urgent need to identify child populations 
where clinical vitamin A deficiency exists, but also those where 
marginal deficiency may be contributing to high child-mortality 
rates, and perhaps morbidity. Newer methods for the assessment 


Update: Xerophthalmia 175 

of subclinical deficiency are being developed, and are the topic of 

the next speaker. 

REFERENCES 

1. WHO PBL Meeting on the Prevention of Childhood Blindness. 
London, England, 29 May-1 June 1990. 

2. Rahmathullah L, Underwood BA, Thulasiraj RD, Milton RC, 
Ramaswamy K, Rahmathullah R, Babu G. Reduced mortality 
among children in southern India receiving a small weekly dose 
of vitamin A. New Engl J Med 1990;323:929-35. 

3. Underwood BA. Vitamin A prophylaxis programs in develop- 
ing countries: past experience and future prospects. Nutr Rev 
1990;48:265-74. 

4. Barclay AJG, Foster A, Sommer A. Vitamin A supplements 
and mortality related to measles: a randomized clinical trial. 
BMJ 1987;294:294-6. 

5. Joint WHO/UNICEF Statement. Vitamin A for measles. 
Lancet 1987 May;i:1067-8. 

6. Markowitz LE et al. Vitamin A levels and mortality among 
hospitalized measles patients, Kinshasa, Zaire. J Trop Pediatr 
1989;35:109-12. 

7. Hussey GD, Klein M. A randomized controlled trial of vitamin 
A in children with severe measles. New Engl J Med 
1990;323:160-4. 

8. Reddy V et al. Relationship between measles, malnutrition, and 
blindness: a prospective study in Indian children. Am J Clin 
Nutr 1986;44:924-30. 

9. Sinha DP. Measles and malnutrition in a West Bengal village. 
Trop & Geogr Med 1977;29:125-34. 

10. Bhaskaram P, Reddy V, Raj S, Bhatnagar RC. Effect of measles 
on the nutritional status of preschool children. J Trop Med & 
Hygiene 1984;87:21-5. 

11. Rahmathullah L, Underwood BA, Thulasiraj R, Milton RD. 
Diarrhea, respiratory infections, and growth are not affected 
by a weekly low-dose vitamin A supplement: a masked con- 
trolled field trial in south Indian children. Am J Clin Nutr 
1991;54:568-77. 



4 


Assessment Methodologies for 
Xerophthalmia, Keratomalacia, and 
Child Mortality including Measles 

Dr Emorn Udomkesmalee 

Signs of xerophthalmia or eye lesions leading to permanent blind- 
ness display vitamin A deficiency at a late phase. It is important, 
therefore, to detect the population at risk as early as possible prior 
to the development of clinical eye signs. Serum concentrations of 
vitamin A or retinol are commonly used to assess the status. A level 
less than 10 pg/dl (0.35-0.70 pmol/L) is low; more than 20 pg/dl 
is adequate. 

Serum vitamin A, which is primarily found in the liver, is a poor 
reflector of the vitamin A that the body stores. A technique to 
estimate the liver store of vitamin A, called the relative dose response 
or RDR, has been developed recently. This test is based on the theory 
that under the condition of high vitamin A stores, serum level is 
little affected by oral doses of vitamin A, whereas a marked increase 
in serum concentration five hours after the oral dose is observed 
with a depleted store. This test calls for obtaining a fasting blood 
sample for vitamin A determination (Ao), administering orally a 
standard dose of vitamin A (600 retinol equivalents), and finally 
providing a low vitamin A breakfast to be followed five hours later 
with a second blood sample drawn to analyze vitamin A (A5). The 
percentage RDR value is calculated by A5-AoxlOO/a5. An RDR 
of more than 20 percent indicates depleted vitamin A stores. 

By using RDR we were able to distinguish a group of Thai 
preschool-age children with inadequate liver stores. Their serum con- 
centrations fell between 20-30 pg/dl, otherwise considered adequate. 
In addition, we observed that children with serum vitamin A above 
30 pg/dl appear to have sufficient liver stores as estimated by RDR. 

Another recent technique is conjunctival impression cytology 
(CIC). This is based upon the observation that early vitamin A 


177 


178 Plenary Session IV— Developments in Control of Blindness 

deficiency results in enlarged, keratinized epithelium with loss of 
goblet cells or the mucus-secreting cells. Imprint specimens were 
obtained from the temporal bulbar conjunctiva, then fixed and 
stained by a standard cytology procedure. 

Normal CIC specimens show abundant goblet cells on a sheet 
of small epithelial cells. As the status declines, fewer goblet cells 
and more enlarged epithelial cells are seen. Abnormal CIC showed 
a complete loss of goblet cells. A current double-masked interven- 
tion study in northeast Thailand indicates that schoolchildren receiv- 
ing a low dose of vitamin A on a daily basis for six months showed 
a marked improvement by restoration of normal conjunctival 
epithelium. Conversely, those without vitamin A supplements main- 
tained the abnormal CIC stage. Continued testing of this techni- 
que is needed to help determine its usefulness for screening 
populations. 

Because the early stage of vitamin A deficiency results in im- 
paired vision in dim light, a rapid dark adaptometry by instrument 
has been developed by a group of research scientists and ophthal- 
mologists affiliated with the Institute of Nutrition at Mahidol 
University, Thailand. The instrument consists of a controlled switch- 
board panel with a small amplifier and timers. A child is seated 
with one eye looking through a channel. A specially modified goggle 
and a black cloth cover the eyes and face to prevent the entry of 
outside light. The bright light is turned on for two minutes followed 
by a dim light as a slide containing a single Thai letter appears on 
the screen. The elapsed time from when the second dim light is 
turned on to the time when a correct letter identification is made 
is termed vision restoration time (VRT). The investigators found 
that VRT corresponded to serum vitamin A in a dose-gradient 
fashion. The lower the serum levels, the longer it took to restore 
vision in dim light. Children with abnormal CIC showed longer VRT. 

VRT manifested the same pattern of seasonal variation on a 
larger population basis as seen with serum vitamin A concentra- 
tions. Moreover, schoolchildren supplemented with a school lunch 
program of vitamin A food sources for one year showed improve- 
ment. Children with the longest VRT improved the most. No im- 
provement of VRT was observed in the control schools. We suggest 
the use of conjunctival impression cytology and rapid dark adap- 
tometry in screening for high-risk populations as well as for use 
as a follow-up for community-based vitamin A intervention pro- 
grams. More work is needed with rapid dark adaptometry. Through 


Assessment Methodologies for Xerophthalmia 179 

consultation with experts at the National Eye Institute in Bethesda, 
Maryland, efforts are underway to improve instrument sensitivity 
and applicability to the younger-age children. 

We deeply appreciate the contribution of the vitamin A assess- 
ment team from the Institute of Nutrition at Mahidol University. 



5 


Update: Onchocerciasis 

Dr Aden ike Abiose 

It is estimated that 86 million persons are at risk of onchocerciasis, 
17.8 million are infected, 336,400 are blind, and a similar number 
suffer severe visual impairment, most of them in Africa. The 
socioeconomic impact of the disease on individuals and com- 
munities is devastating, and forms the basis for justifying the massive 
international expenditure on its control. 

The operations of the Onchocerciasis Control Program in West 
Africa started in 1975 and were based solely on the control of the 
vector Simulium damnosum until 1987, when Ivermectin, an ef- 
fective and safe microfilaricide, was registered. This drug has in- 
creased the prospects for large-scale community therapy of the 
disease, and provided an alternative control method that is being 
investigated in Nigeria and other countries of West Africa. A sum- 
mary of the Nigerian experience is presented. 

INTRODUCTION 

The control activities of the Onchocerciasis Control Program in West 
Africa (OCP) started in 1975 and initially involved seven countries. 
Activities have been extended into four other countries, bringing 
the area now covered to 1.3 million square kilometers. At the in- 
ception of the OCP, there was no drug suitable for mass distribu- 
tion in severely affected communities. Consequently, the approach 
was to interrupt Onchocerca volvulus transmission through con- 
trol of its vector, Simulium damnosum. This method has proved 
successful, with virtual interruption of transmission accomplished 
over some 600,000 square kilometers in the original area as dem- 
onstrated by entomological and epidemiological methods. 1 The 
overall complexity and cost of executing the program, however, 
makes it unlikely that it can be replicated in other affected African 
countries. 

The registration of Ivermectin provided a safe alternative for 


181 


182 Plenary Session IV— Developments in Control of Blindness 

the control of the disease that is currently being tried in other West 
African countries, including Cameroon, Liberia, Nigeria, and Sierra 
Leone. Experience from various studies has uniformly demonstrated 
the efficiency and safety of the drug. Adverse effects have been few 
and essentially minor 2 3 4 5 and are milder and less frequent with 
subsequent doses. Most of the reactions experienced are the result 
of microfilarial death, and consist of itching, rash, headache, 
arthralgia, and myalgia. Others include pain, tenderness, swelling, 
tachycardia, and hypotension. However, few severe reactions have 
been recorded. The most significant effect is severe symptomatic 
postural hypotension (SSPH). Severe asthma is also a rare reaction. 
Ivermectin is a microfilaricide without macrofilaricide effect. This 
makes it effective when given on an annual basis. 


BACKGROUND INFORMATION ON NIGERIA 

The Federal Republic of Nigeria is a country situated in West Africa 
whose western border forms the eastern border of the OCP. The 
surface area of the country is approximately 924,000 square kilo- 
meters. The population is estimated to be about 120 million. Like 
most developing countries, the population pyramid is broad at the 
base: most of the population is very young and life expectancy is 
only 50 years. A study of geography and ecology shows rain forests 
in the south, Sudan savanna in the middle-belt, and sahel savanna 
to the extreme north. For administrative purposes the country is 
divided into 21 states and the Federal Capital Territory. 

The national health policy that came into effect in 1988 is based 
on the primary health-care system. The federal government pro- 
vides tertiary health care, the state governments provide secondary 
health care, and the local governments, of which there are 450, pro- 
vide primary health care. 


ONCHOCERCIASIS-CONTROL ACTIVITIES IN NIGERIA 

Onchocerciasis was first reported in Nigeria in 1908 and has been 
recognized as a major cause of blindness in northern Nigeria since 
the pioneer work of Rodger and Budden. 6 * 7 The latter found blind- 
ness prevalence rates as high as 5.6 percent in the hyperendemic 
Hawal Valley area of the present-day Gongola State. With the suc- 
cess of the OCP operations, it is estimated that Nigeria is presently 


Update: Onchocerciasis 183 


the most onchocerciasis-endemic country in the world, containing 
more than 60.0 percent of West Africa’s cases. According to World 
Health Organization estimates, 40 million Nigerians are at risk to 
the disease, approximately 1 million are infected, and about 120,000 
are blind from it. 8 It is hoped that up-to-date information will 
become available after collection of the recently concluded nation- 
wide epidemiological survey commissioned by the National On- 
chocerciasis Control Program (NOCP). 

There have been isolated attempts at vector control by larvicide 
in different parts of Nigeria since the 1950s, including the Oji River, 
the Mimi River, the Abuja area, the Hawal River, and later the 
Kainji dam area, initially using DDT and later changing to 
temephos. 9 101112 The main problem encountered has been reinva- 
sion, which unfortunately has led to the abandonment of most of 
the projects. 

The success of the OCP renewed interest in onchocerciasis con- 
trol in Nigeria and led to the creation of the National Onchocer- 
ciasis Control Program in 1981. At inception, the plan was to employ 
vector control similar to that being done in the OCP area. Soon 
it became obvious that the country did not have the financial or 
technical expertise to execute such an expensive and complicated 
program. Activities of the NOCP were therefore limited to planning, 
data collection, policy decisions, fund attraction, and training of 
personnel. With the advent of Ivermectin, the decision was made 
to distribute the drug to severely affected communities. The Mec- 
tizan Expert Committee has approved the release of the first con- 
signment of Ivermectin to Nigeria before the end of 1990. 


COMMUNITY CONTROL OF ONCHOCERCIASIS 
WITH IVERMECTIN IN NIGERIA 

There are several ongoing projects in Nigeria that have contributed 
to the knowledge of onchocerciasis and should be immensely 
valuable in planning future control activities in Nigeria. 

The level of community acceptance and incidence of serious 
adverse effects of using Ivermectin for onchocerciasis are being 
studied in a placebo-controlled trial based in Kaduna State. In a 
population of 12,702 recorded at census, 10,492 (82.6 percent) were 
age five years or more. Of the total, 8,140 people were eligible for 
dosing, and 6,270 (77.0 percent) were dosed with either Ivermectin 


184 Plenary Session IV— Developments in Control of Blindness 

or placebo. Of the 3,139 dosed with Ivermectin, 15.9 percent ex- 
perienced minor adverse events: itching (9.5 percent), headache (4.2 
percent), dizziness, edema, arthralgia, or fever (1.4 percent). Coverage 
increased marginally at second dosing and adverse events were fewer 
and milder. Pregnancy and lactation accounted for 67.0 percent of 
all exclusions. (There is a great need to pay particular attention to 
the female population in any mass control campaign in Nigeria.) 

Of the 6,833 persons examined, 609 (8.9 percent) persons were 
found to have ophthalmic signs consistent with optic nerve disease. 
These and an enriched random sample had a detailed eye examina- 
tion including fluorescein angiography. No serious adverse ocular 
events were recorded. There was no worsening of visual function 
and optic neuritis, known to occur with diethylcarbamazine. The 
question of whether annual dosage with Ivermectin would prevent 
visual deterioration remains to be assessed at the two-year follow- 
up visit. 13 

The study of the vectors and dynamics of transmission of 
onchocerciasis in relation to optic nerve disease in northern Nigeria 
has just been concluded. Findings show a classic hyperendemic focus 
in the West African savanna area. Cytotaxonomic determinations 
showed S. damnosum s.s. to be the dominant vector at Kudaru. 14 

The drug trial offered the opportunity to study the mechanisms 
of resistance and the immunopathology of onchocercal lesions 
through the study of people with and without patent disease and 
with and without various onchocercal lesions. The modulations of 
these responses by treatment with Ivermectin is also being 
investigated. 15 

Another project based in Enugu Anamhra State in southeastern 
Nigeria is studying the epidemiology of onchocerciasis in a forest 
mosaic area. The study area is Achi and the affected communities 
are at varying distances from the Oji River. Community distribu- 
tion of Ivermectin has commenced. 

An offshoot of these studies has been the collection of baseline 
data that provides accurate population-based blindness prevalence 
figures, not only in onchocerciasis-endemic areas, but also in the 
non-endemic to hypo-endemic control areas. Whereas the blind- 
ness prevalence rate was found to be 3.2 percent in the high me- 
soendemic area, it was only 0.6 percent in the hypoendemic area. 
The control of onchocerciasis in these endemic areas is a most im- 
portant intervention method for the control of blindness. 

Rapid assessment methods for the level of community infection, 


Update: Onchocerciasis 185 


which are of operational importance for mass distribution of 
Ivermectin, have also been investigated. 

Rapid estimation of onchocercal endemicity using “leopard skin” 
has been investigated by Edungbola and others, 16 whereas the com- 
munity blind eye test has been investigated by Jones and others. 17 
Other teams are also trying to develop safe, reliable, and sustainable 
means to mass distribute Ivermectin to the remote rural communities 
where it is needed. 18 

The National Plan for Ivermectin Delivery and its Interrelation- 
ship with the National Program for the Prevention of Blindness: 

Mass distribution of Ivermectin to needy communities is expected 
to start before the end of 1990 in one local government area of each 
of the four health zones. The plan is to retrain primary health-care 
workers where they reside to carry out the distribution. In other 
communities, individuals who have been selected by the community 
will be given a short training program enabling them to function 
as community-based distributors acting as voluntary village health 
workers. 

Spot prevalence surveys will be carried out to determine com- 
munities that qualify for mass chemotherapy. Only communities 
with at least a 40 percent prevalence rate by skin snip of micro filarial 
positivity will receive community chemotherapy. In communities 
with lower endemicity, only individuals with clinical disease will 
be treated. The teams distributing Ivermectin will be retrained to 
collect accurate information on blindness and blinding diseases in 
all communities in which they are working. This is possible because 
the same directorate in the Federal Ministry of Health is coordinating 
both programs. When additional funds become available, activities 
will be extended to other local governmental areas. 


CONCLUSION 

Onchocerciasis is still a major blinding disease in many parts of 
West Africa. The majority of those still affected are in Nigeria. 
Onchocerciasis control is presently receiving urgent international 
and government attention. Although vector control is the ideal way 
to interrupt transmission of the disease, this has been found to be 
too expensive and too complex to be employed in Nigeria. Ivermectin 
distribution to communities has been chosen as a way of reducing 


186 Plenary Session IV— Developments in Control of Blindness 


the human disease burden, although it is understood that this may 
have to be combined with focal vector control in areas with severe 
disease. With careful planning, it should be possible to control 
Onchocerciasis in Nigeria. 

ACKNOWLEDGEMENTS 

The data presented are from Projects 870456 and 890134 supported 
by the UN DP/ World Bank/ WHO special program for research and 
training in tropical diseases. Some of the staff are supported by 
the Leverhulme Trust. The Kaduna State Eye-Care Plan is supported 
by Sight Savers and the Kaduna State Ministry of Health. The British 
Council for the Prevention of Blindness funded one ophthalmologist 
who participated in the pilot project. 

REFERENCES 

1. Philippon B, Remme JH, Walsh JF, Guillet P, Zerbo DG. En- 
tomological results of vector control in The Onchocerciasis Con- 
trol Programme. Acta Leidensia 1990;59(l&2):79-94. 

2. World Health Organization. Report of a meeting of the TDR/ 
OCP/OCT subcommittee for monitoring of community trials 
of ivermectin. UNDP/World Bank/WHO Special Programme 
for Research and Training in Tropical Diseases. 1989; p. 1-16. 

3. Diallo S, Aziz MA, Larivierer M, Diallo JS, et al. A double blind 
comparison of the efficacy and safety of ivermectin and 
diethylcarbamazine in a placebo controlled study of Senegalese 
patients with onchocerciasis. Trans Roy Soc Trop Med Hyg 
1986;80:927-34. 

4. Awadzi K, Dadzie KY, De Sole G, Remme J. Reactions to 
ivermectin treatment in onchocerciasis patients. Acta Leiden- 
sia 1990;59(l&2):193-9. 

5. Stilma JS, Rothova A, Van der Lelij G, Wilson WR, Barbe RF. 
Ocular and systemic side effects following ivermectin treatment 
in onchocerciasis patients in Sierra Leone. Acta Leidensia 
1990;59(1&2):207-10 

6. Rodger FC. Blindness in West Africa. London, HK Lewis; 1959. 

7. Budden FH. The epidemiology of onchocerciasis in Northern 
Nigeria. Trans Roy Soc Med and Hyg 1956;50(4):366-78. 


Update: Onchocerciasis 187 


8. World Health Organization Expert Committee on Onchocer- 
ciasis (1987). Third Report, Technical Series 752. 

9. Crosskey, RW. First results in the control of Simulium 
damnosum Theobald (Diptera, Simuliidae) in Northern Nigeria. 
Bull Wld Hlth Org 1962;27:491-510. 

10. Davies JB, Crosskey RW, Johnston MRL, Crosskey ME. The 
control of Simulium damnosum at Abuja, Northern Nigeria 
1958-1960 Bull Wld Hlth Org 1962;27:491-510. 

11. Walsh JF. The control of Simulium damnosum in the River 
Niger and its tributaries in relation to the Kainji Lake Research 
Project, covering the period 1961 to 1969. WHO mimeo 
PD/70.4,1970. 

12. Gregory WG. A brief review of control of the vectors of on- 
chocerciasis in Nigeria. Proceedings of the first national con- 
ference on onchocerciasis 1982;1:15-9. 

13. Abiose A. Report to the September 1990 WHO TDR/FIL Steer- 
ing Committee. 

14. Vajime CG, Dunbar RW, Gregory WG, Akpa AUC, Nock IH. 
Present status of the Simulium damnosum complex in Nigeria: 
identification, distribution, ecology, vectorial capacity and 
resistance to insecticides. WHO/ONCHO Informal consulta- 
tion on Simulium damnosum complex, Bamako, Mali 2-6 
November, 1987. 

15. Murdoch ME, Hay RJ, Ramnarain N, Lucas S, Jones BR, 
Abiose A. A clinical classification and grading of the cutaneous 
changes in onchocerciasis and histopathological findings. Brit 
J Dermatology 1990;123(Suppl37):28. 

16. Edungbola LD, Watts SJ, Oni GA. Rapid estimation of on- 
chocercal endemicity using “leopard skin” (LS). Acta Leiden- 
sia 1990;59(1&2):467. 

17. Babalola OE, Jones BR, Abiose A, Cousens S, Liman I, Bolarin 
I. The “Blind Eye Community Test” for assessing onchocercal 
disease burden and endemicity. (In press). 

18. The Kwara State Blindness Prevention Program. Report on 
Evaluation of Ivermectin Distribution in Borgu. LGA June, 
1990. 



6 


Use of Ivermectin in 
Onchocerciasis Control 

Drs. K.Y. Dadzie, G. De Sole , and J. Remme 

Ivermectin, a macrocyclic lactone, has been shown in clinical and 
community-based trials to be an effective microfilaricide, easy to 
deliver, and safe for mass treatment of human onchocerciasis. The 
Onchocerciasis Control Program (OCP) in West Africa has treated 
over 250,000 persons in high-risk areas since the registration of 
Ivermectin in 1987. Some of the areas that are under treatment 
underwent ophthalmological examinations before distribution of 
Ivermectin. 

In this presentation, ocular changes which have occurred over 
a two-year period in populations that have undergone annual treat- 
ment with Ivermectin since October 1987 will be described. The 
populations described live in the three most hyperendemic villages 
in the savanna of Asubende in northern Ghana and have undergone 
annual treatment with Ivermectin since October 1987. The criteria 
for subjecting communities to Ivermectin treatment in the OCP area 
will be explained. 

The study population that underwent ophthalmological exam- 
inations consisted of 568 persons at least five years of age who were 
drawn from the census of 864 people living in the three holo-endemic 
villages with a Community Microfilarial Load (CMFL) ranging from 
58 to 73 mf/s. The prevalence of infection as measured by skin snip 
ranged from 85.6 percent to 87.3 percent. The prevalence of blind- 
ness as measured by visual acuity was found to range from 1.2 per- 
cent to 4.4 percent and increased from 1.8 percent to 13.0 percent 
when the results of visual field test were considered. In this study 
334 persons were treated twice, 89 once, and 14 were not treated 
because of the exclusion criteria. All had full ophthalmological ex- 
aminations throughout the study period. 

Two months after treatment, Ivermectin had reduced the skin 
microfilarial loads in the population treated twice by 96 percent 


189 


190 Plenary Session IV— Developments in Control of Blindness 

of their original pretreatment value. Twelve months after dosing, 
however, the microfilarial loads had increased to 40 percent of the 
pretreatment value. Following the second dosing after one year, 
similar changes in the skin microfilarial loads were registered at ex- 
aminations 14 and 24 months after the start of the study. 

The mean ocular microfilarial loads, as illustrated by the 
microfilarial count in the anterior chamber of the eye and in the 
cornea, also fell to very low levels four months after treatment but 
rose again 12 months after treatment. A similar pattern of fluc- 
tuating ocular microfilarial loads was repeated after the second an- 
nual dosing 16 and 24 months after the start of the study. Most 
of the people who still had microfilarial loads after 24 months had 
only very low loads, even though a considerable number of the 
population under study had very high ocular microfilarial loads 
of 32 and more before the study started. This implies that the risk 
of developing eye lesions in the populations has been reduced con- 
siderably or is being eliminated. 

Two rounds of Ivermectin treatment significantly reduced the 
occurrence of the early stage of iridocyclitis (defined as any acute 
or torpid iridocyclitis without synechiae) to insignificant levels. The 
prevalence of advanced iridocyclitis showed only a mild downward 
trend. A regression that was less pronounced was recorded for 
sclerosing keratitis. Analysis of lesions taken from the posterior seg- 
ment of the eye showed that these lesions have remained stable over 
the two year period. These results suggest that Ivermectin is suitable 
for controlling onchocercal eye morbidity in the short term and 
could prevent blindness due to onchocerciasis if the drug were given 
annually. 

The study also developed a model prediction showing that an- 
nual distribution of Ivermectin over a sustained period of time can 
control onchocercal blindness. However, the prevalence of onchocer- 
cal blindness can attain the original levels over time if the treat- 
ment is stopped, even if it is stopped after 25 years of annual 
Ivermectin treatment. This implies that Ivermectin distribution for 
prevention of blindness must be sustained over a very long period 
of time; this calls for a cost-effective strategy for distribution. 

In the West African savanna blinding onchocerciasis has become 
a community problem with increasing intensity of infection in the 
community. Over 80 percent of the onchocercal blind are found 
in communities with CMFL of 10 mf/s or more, or where the 
prevalence of infection is 55 percent or more where only about 15 


Use of Ivermectin in Onchocerciasis Control 191 

percent of the population at risk of onchocerciasis infection live. 
In communities with CMFL of 4 mf/s or more, or prevalence of 
infection of 40 percent or more, 97 percent of the onchocercal blind 
are found among about 30 percent of the population at risk of in- 
fection living in the endemic area. This clearly demonstrates that 
to ensure cost-effectiveness and maintain a sustained delivery ef- 
fort Ivermectin distribution should be directed to the communities 
with CMFL of 4 to 10 mf/s or prevalence of infection of 40-55 
percent. Before any Ivermectin distribution starts there must be an 
epidemiologic mapping of the area to identify the communities most 
in need of treatment to ensure meeting the objective of the exercise. 




























































7 


Organization of a Trachoma-Control 
Program in Africa, with 
Special Emphasis on Kenya 

Prof. Henry S. Adala 

INTRODUCTION 

Trachoma remains a major cause of blindness in the world. More 
than 500 million people are affected and between 6 and 9 million 
people are blind from trachoma. In addition, many more are only 
partially sighted as a result of the infection. Trachoma is to a large 
extent a self-limiting disease and is dependent upon the commun- 
ity in which it is endemic. 

Blinding trachoma is associated with seasonal bacterial infec- 
tion. Its severity also depends on the rate of re-infection of an in- 
dividual by Chlamydia trachomatis through eye-seeking flies. The 
disappearance of the disease is closely associated with economic 
development as well as social and behavioral changes. In several 
parts of the developing world, trachoma is a problem among rural 
communities where ignorance and poverty are commonplace. 


BLINDNESS IN AFRICA 

In Africa, trachoma is indeed a major public health problem. Blind- 
ness in most African countries ranges from between 0.5 percent and 
1.0 percent. In hyperendemic trachoma areas, however, this rate in- 
creases to 2.0 percent in East Africa and 4.0 percent in North Africa. 
A review of the prevalence of blindness in Africa between 1968-81, 
using binocular vision of 3/60 or less as the definition of blind- 
ness, found the following in hyperendemic trachoma areas: 


193 


194 Plenary Session IV— Developments in Control of Blindness 


Country 

Year 

Blindness Prevalance 
from Trachoma 

North Africa: 

Egypt 

1974 

4.7% 

Morocco 

1968 

4.1% 

Sudan 

1976 

4.5% 

East Africa: 

Zambia (west) 

1978 

2.3% 

Tanzania (central) 

1979 

2.3% 

Kenya (Meru) 

1981 

1.9% 

Malawi 

— 

1.3% 

Zimbabwe 

— 

1.0% 


According to information obtained from the proceedings of the 
sub-regional prevention of blindness seminar for East and Central 
Africa in Moshi, Tanzania, in 1984, trachoma is a leading cause 
of blindness in the following countries: Kenya (16 percent), Malawi 
(15 percent), Somalia (30 percent), Tanzania (25 percent plus other 
corneal scars), and Zimbabwe (30 percent plus other corneal scars). 
In addition, trachoma is a major cause of blindness in Ethiopia, 
Uganda, and Sudan. 

CONTROL PROGRAMS 

Control programs for trachoma have existed for the last 40 years. 
Identification and knowledge of the relevant epidemiologic deter- 
minants is necessary for the various communities to differentiate 
between blinding trachoma and non-blinding trachoma, for example: 
Concomitant bacterial infection; 

Degree of re-infection by chlamydia trachomatis; 
Transmission agents (flies, clothing, and personal contact); 
Poor water supply and poor personal hygiene; 

Open faecal and rubbish disposal; and 
Overcrowding 

TRACHOMA IN KENYA 

In Kenya, trachoma is second only to cataract as a cause of 
blindness. 


Organization of a Trachoma-Control Program in Africa 195 


Causes of Blindness in Kenya 


Cause 

Percent 

Senile Cataract 

38% 

Trachoma 

19% 

Glaucoma 

9% 

Macular Degeneration 

7% 

Refractive Errors 

6% 

Others 

22% 


Trachoma in Kenya is a localized problem and the prevalence 
of both current inflammation (active trachoma) and inactive 
trachoma varies widely. In addition, various factors are interdepen- 
dent. For example, an insufficient source of water is closely related 
to poor personal hygiene. People living in the arid areas of rural 
Kenya, for instance the Masai of the Kajiadc and Narok Districts 
and the Pokot and Njemps of the Baringo District, tend to have 
a higher prevalence of trachoma. Because these tribes are herdsmen 
and depend upon livestock for economic livelihood, they live in close 
proximity to their animals and are exposed to the persistent eye- 
seeking flies that have been implicated in the spread of the disease. 

The organization of the trachoma-control program in these areas 
is incorporated in the National Prevention of Blindness Program, 
which attempts to treat all preventable and curable eye diseases. 
Shrinking resources and population increases make this the desired 
approach. Trachoma must be challenged at two levels, the primary 
level and the secondary level. 

Primary Level 

The target population is regularly visited by Clinical Ophthalmic 
Officers (COO) using mobile eye units. The Officer identifies the 
disease and records the stage (active or inactive, with trichiasis or 
corneal opacity). The COO distributes tetracycline to the patients 
to be used twice daily until the second or third month when they 
are revisited and the treatment continues. Others are instructed how 
to apply the ointment. During the visit, the Clinical Officer gives 
a brief talk on the importance of face washing, the necessity to keep 
animals away from dwelling houses, and the dangers inherent in 


196 Plenary Session IV— Developments in Control of Blindness 

the traditional habit of animal fat anointing. In the Narok District, 
the MEU covers approximately 1,500 kilometers per month and rural 
health facilities are visited at least four times per year. They are 
now visiting Manyattas more efficiently. 

In Kenya, we established the Primary Eye-Care Unit in 1986. 
It was headed by an ophthalmologist trained at the International 
Centre for Eye Health (ICEH) in London and run by two Clinical 
Officers also trained at ICEH. The task of this unit is to create and 
sustain awareness about the curable and preventable causes of blind- 
ness, including trachoma. They hold seminars and workshops dur- 
ing which basic eye hygiene is stressed and possible ways of 
eliminating environmental health hazards that might lead to blind- 
ness are explored. 

The Unit also tries to warn against overcrowding. However, ex- 
pecting change is unrealistic because overcrowding is linked to the 
socioeconomic status of a family and the cultural background of 
the region. The primary level therefore demands community 
participation. 

Secondary Level 

The same clinical officers identify entropion with trichiasis and refer 
patients to their district hospital where entropion correction is per- 
formed. In some cases, this can be done during mobile eye clinics 
by the Chief Ophthalmic Officer. 

Tertiary Level 

Keratoplasties are performed at a limited rate due to the lack of 
donor material. The success rate of keratoplasty done for typical 
trachomatous vascularized corneal opacity is very poor. 

The missing links in trachoma control are knowledge, attitude, 
and practice. Cultural differences must be taken into consideration; 
and studies should be culturally aware and population-specific. 
Evidence shows that mass treatment can change the level of 
endemicity of trachoma; however, it is too expensive in most coun- 
tries where trachoma occurs. 

SUMMARY 

In summary, blindness from trachoma, which is still a major 
problem in most African countries, requires cost-effective programs 


Organization of a Trachoma-Control Program in Africa 197 

that are undertaken only after understanding the cultural and social 
background of the population at risk. An ophthalmologist is not 
the most effective staff member to tackle this problem. Clinical Of- 
ficers, nurses, and health orderlies should communicate directly with 
the community. Most important is the participation of the com- 
munity itself in control of trachoma. Mass chemotherapy by use 
of tetracycline is still preferred for active trachoma and should be 
supplemented by appropriate health education on face washing, per- 
sonal hygiene, waste disposal, and overcrowding. 







8 


Low-Cost Spectacles 

Dr Francisco Contreras 

One of every five persons and 15 percent of the school population 
in Latin American countries need eyeglasses to improve their vision 
and consequently their capacity to learn and work. Three of the 
causes of this situation are: the high cost of the eyeglasses, the lack 
of personnel to perform the refraction, and the fact that there is 
little interest to start low-cost spectacles projects. 

Through the assistance of Helen Keller International, our proj- 
ect started two years ago with the creation of a small production 
unit in the National Institute of Ophthalmology in Lima, Peru. 
Production work began with an assembly phase, rehabilitating 
secondhand frames donated by Operation Eyesight Universal. This 
project began on a small scale trying to cover the demand of the 
outpatient department of the Institute. 

More recently, our Institute designed a medium-term plan 
to further develop this project. The following stages have been 
established: 

1. Spectacles assembly (includes lens-edging) 

The first stage involved the assembly of glasses produced in 
Peru and the rehabilitation of secondhand frames. This stage 
required some basic elements including an edging machine, 
which was easy to get inexpensively in the local market. Also, 
the Institute hired an experienced optics technician. 

2. Lens-grinding process 

This is a future development phase that will require funds 
to get the necessary equipment. (We are not in this stage yet.) 


EXPANSION OF THE PROJECT 

This pilot facility is currently limited to cover the demand of patients 
of the Institute and certain ongoing activities, like the Cataract- 


199 


200 Plenary Session IV— Developments in Control of Blindness 

Free Zone programs. We must now expand this program to serve 
a broader population. 

Such a project has to be economically self-reliant. That is, it 
must be able to meet its out-of-pocket expenses. The amount of 
money collected from patients, or raised from donors, must at least 
equal the costs associated with establishing and operating the 
production unit, including salaries, equipment, supplies, and future 
expansion. 

To bring about the acceptance of this project by local opticians, 
we have followed two strategies. First, we have tried to explain that 
this program is dedicated to the benefit of only poor people, who 
would have no possibility of buying eyeglasses from opticians. In 
addition, we have developed a nine-month training course for op- 
ticians. Our first course, which had 35 attendants, included the par- 
ticipation of ophthalmologists and well-qualified opticians within 
the community. Practice was performed in our eyeglasses facility 
unit. 

Finally, I would like to mention that we have collaborated with 
Helen Keller International (HKI) to prepare of a practical hands- 
on-guide called “Providing Low-Cost Spectacles: A Practical Guide,” 
which discusses the economic and technical aspects of such a proj- 
ect. For more information, please write to HKI, 15 West 16th Street, 
New York, NY, 10011, USA. 


9 


Providing Low-Cost Spectacles 
and Eye Medications 

Dr Joseph Taylor 

I am most grateful for this opportunity of sharing with you all some 
of our experiences, which include both successes and frustrations, 
in trying to provide the bricks and mortar that are needed to im- 
plement the many national eye-care programs that are now spring- 
ing up worldwide — a development which is due in no small part 
to the vision and energy of those who initiated this international 
forum. 

I have had the good fortune (if I may be permitted a short 
historical digression) to be present at all the General Assemblies 
of IAPB since the first at Oxford in 1978. I well remember, on that 
occasion, having to defend the basic idea that the eye problems of 
the developing world need their own specific solutions. This is now 
the universally agreed upon basis of our discussions, which shows 
that a great deal of progress has been made in the past 12 years. 
However, with the rapid developments and intense sophistication 
of methods since 1978, we are in some danger of forgetting that, 
more than ever, we need to concentrate on developing our own solu- 
tions rather than taking over the norms of western methods of 
treatment. 

The basic framework within which we have to work includes 
the increasingly difficult economic climate. Many annual health 
budgets are still less than $10 per capita. It is to this end that sim- 
ple optical workshops, where finished lenses are put into standard 
frames (edging workshops), have been developed. This has occur- 
red especially on the African continent, though similar endeavors 
are also to be widely found in Asia. Even the United States is not 
unconscious of this possible market. Those of you who pass through 
international airports will, I am sure, have purchased ready-made 
reading glasses between one flight and the next. I certainly have! 

Often patients have travelled long distances to see an eye worker. 


201 


202 Plenary Session IV— Developments in Control of Blindness 

We must seek therefore to provide the needed optical correction on 
this same occasion, instead of sending them on a further journey 
with just an optical prescription rather than an actual pair of glasses. 

A further development has been surfacing of optical blanks or, 
even more basically, the production of standard spherical lenses from 
window glass by use of a lens generator. These will be illustrated 
by the demonstration at the end of the Assembly by the optical 
workshops of East Africa, which I hope some of you will visit. 

The production of cheap plastic frames is an everyday fact in 
India, China, and other countries of Asia, but awaits development 
in much of Africa and other more remote developing countries. 
However, the aim of having available to the eye patient a ready- 
made, finished pair of cheap glasses on his first consultation is well 
within reach. If the ministries of health, who often have surpris- 
ingly expensive drugs available in their medical stores, could be per- 
suaded to add to their stocks ready-made spectacles, which are the 
“optical medicine” required by so many eye patients, then another 
important step will have been taken. One final word on this “op- 
tical medicine”: patients do not demand a free pair of glasses. They 
expect them to be available and affordable — by which we usually 
mean the equivalent of one week’s minimum wage or about $5-10. 
This is what should be our aim. WHO and Helen Keller Interna- 
tional have produced useful booklets that set out the factors 
associated with the production of low-cost spectacles. 

In the ever-increasing urban poor populations, we should aim 
at persuading the commercial optical outlets to produce afford- 
able, ready-made glasses as part of their service to the community. 
Such spectacles should be made available in addition to offering 
the more fancy and sophisticated spectacles that are their present 
stock-in-trade. 

An even larger number of eye patients require standard eye 
medications, especially antibiotic drops for common conjunctivitis 
and an affordable steroid preparation. Those medications available 
through commercial pharmaceutical outlets are usually unaffordable 
and, in any case, most of those who need the medication are com- 
pletely remote from ordinary sources. Some of the commercial 
preparations are, in addition, professionally undesirable and mis- 
leading, such as the all-too-common steroid antibiotic mixtures. 

It was with these constraints in mind that the methods for local 
production of eye drops have been developed. In principle, these 
methods use recyclable containers, and confine themselves to essen- 


Providing Low-Cost Spectacles 203 


tial eye drugs, which are always generic preparation, not branded 
products. Good quality water is produced by distillation, which can 
now be done with solar energy; drops are prepared with a preser- 
vative and antioxidant agent to ensure maximal stability during heat 
sterilization; filtration removes particulate matter; then dispensing 
and sealing into pre-sterilized containers, and final sterilization of 
the finished drop in its container is followed by post-sterilization 
inspection before labelling and storage. 

Eye drops prepared in this manner have proved to be of high 
quality and safety, at a cost which is only a fraction of the equivalent 
commercial product. Only one room is required for the whole pro- 
cedure and, though expert pharmaceutical staff are to be preferred 
and are becoming more widely available for this work, even non- 
pharmaceutical staff specifically trained for the production of eye 
drops (often a member of the eye-care team) have proved acceptable 
so long as they have been carefully selected and are regularly 
supervised. 

India and China are again in the forefront for producing cheap 
commercial eye drops; but even in those parts of the world, where 
these economical preparations are available, a considerable saving 
can still be made by local preparation. In addition, there is the ex- 
tra advantage of having the drops available when and where they 
are needed. WHO has been a real stimulus, not only in the promo- 
tion of a model list of essential eye drugs, but also in the produc- 
tion of a manual for the local production of eye drops, which will 
be available shortly. 

There can be no doubt that, as national eye programs develop, 
the need for affordable and available spectacles and eye medications 
will increase; and I feel certain that the commitment and hard work 
required will not be lacking. IAPB will, I am sure, continue to pro- 
vide the inspiration and political impetus to achieve these goals. 



10 


Use of Portable YAG Laser 
to Treat Glaucoma 

Dr. Henry S. Newland 

Recent survey data indicate an economic blindness rate in Myan- 
mar (formerly Burma) of 2.59 percent or 25.9 per thousand popula- 
tion; the WHO-recommended acceptable rate is 5 per thousand. 
Cataract accounts for 75 percent of this blindness, with glaucoma 
and corneal disease being responsible for most of the remainder. 
Unfortunately, no population-based data exist on the prevalence 
of glaucoma, including rates comparing acute angle-closure 
glaucoma (ACG), chronic angle-closure glaucoma (CAG), and open- 
angle glaucoma (OAG). Hospital statistics in 1983 indicate that more 
than 80 percent of glaucoma that is treated in hospitals is ACG. 
This is confirmed by similar situations in other Mongoloid popula- 
tions. There is a preponderance of female glaucoma in Myanmar 
and more epidemiological data are needed to identify patients at risk. 

Many ACG cases present late as absolute glaucoma — for which 
treatment, either medical or surgical, is of little or no use. Many 
of these patients, particularly those from remote and rural areas, 
refuse prophylactic surgery on the fellow eye (which has good vision) 
because they are afraid of losing their only seeing eye. Medical treat- 
ment, if available, is expensive after the patient has been discharged 
from hospital. Screening the population for ACG and OAG will 
be difficult without accurate epidemiological data to identify pa- 
tients at risk, who then will be difficult to convince to accept treat- 
ment. It is likely, however, that a noninvasive treatment would be 
acceptable to those individuals who have suffered an attack in 
one eye. 

The surgical YAG laser provides an alternative noninvasive tool 
that was not portable until recently. Prophylactic surgical treatment 
for glaucoma requires admission to a hospital, and many patients 
live too far away. There are also complications, and therefore many 
patients are frightened. The portable laser represents a major 


205 


206 Plenary Session IV— Developments in Control of Blindness 

advance in technology and opens the possibility of its use in the 
field to create a full thickness hole in the iris without opening the 
eye. As with any surgery there can be complications, including in- 
creased intraocular pressure, bleeding, and inflammation. The aims 
of the laser trial in Myanmar were as follows: 

1. To assess the feasibility of using a portable YAG laser as a 
prophylactic measure. 

2. To demonstrate the use of the Nd-YAG laser and to train local 
ophthalmologists to operate the system. 

Several field trials have been carried out with the Q -switched 
Neodymium-YAG (Nd-YAG) laser, which has been shown to be an 
effective instrument for producing iridotomies in pupillary block 
glaucoma. This laser has been found to require fewer pulses for 
iridotomy formation, there is less chance of iridotomy closure, and 
it is a smaller and lighter instrument than the previously used Argon 
laser. The use of this laser system, its durability, and the results of 
treatment will now be presented. 

METHODS AND MATERIALS 

The system used was a 7905 Nd-YAG laser (Coherent Medical) which 
is slit-lamp mounted and carried in a padded reinforced case 
weighing 26.3 kg (54 lbs) and measuring 58 X 43 X 29 cm (23 X 
17 X 11 inches). It has an energy range in millijoules to 10 and is 
air cooled. It may be operated using a self-contained battery located 
in the slit lamp mountings or with 120 or 220 volts AC. For this 
trial the local 220 volt power supply was used. The system was easily 
transported in all modern forms of transport including aircraft, 
vehicles, and trains. 

The Eye, Ear, Nose, and Throat Hospital in Yangon, capital of 
the Union of Myanmar, is the major referral center for the country 
where an estimated 75-100 new cases of acute-angle closure glau- 
coma are seen every week. There are 75 ophthalmologists in the 
country, 32 of whom were selected to participate in the trial. Subse- 
quently, the system would be taken to the field and operated by 
ophthalmologists in different regions. In addition to the 7905 Nd 
YAG laser system, a Schiotz tonometer, a three-mirror contact lens, 
an Abraham YAG iridectomy lens, and appropriate ophthalmic 
pharmaceutical agents were on hand. 

The effect of YAG laser on paper was first demonstrated at the 


Use of Portable YAG Laser to Treat Glaucoma 207 

slit lamp and then each ophthalmologist watched the procedure be- 
ing performed through the observer tube. On the next patient the 
ophthalmologist performed an iridotomy under supervision. On 
entry into the trial, each patient signed an informed consent. The 
Snellen visual acuity was determined and an ophthalmic examina- 
tion was performed, including slit-lamp examination, gonioscopy, 
and Schiotz tonometry. Patients with a gonioscopic narrowed 
anterior chamber angle approach without visible ciliary body for 
180x (without indentation) were included in the study, as were pa- 
tients with elevated intraocular pressures. Each eye had preoperative 
2.0 percent pilocarpine hydrochloride and 0.1 percent dexamethasone 
drops administered prior to treatment. The portable 7095 Nd-YAG 
system was operated on existing hospital and office furniture. 

The treatment protocol followed was similar to that for a field 
trial in Eskimos. 1 Topical anaesthesia was applied using ametho- 
caine drops. The Abraham YAG contact lens was then applied to 
the eye. All eyes were treated peripherally in the superior nasal quad- 
rant aiming to produce an iridotomy within an iris crypt. A stan- 
dard energy setting of 6-8 millijoules in one pulse was used in the 
first instance. 

If at the first attempt the iris was not adequately penetrated the 
energy level was increased and a repeat attempt was made. If pig- 
ment or blood covered the iridotomy site, a second site was then 
chosen in the superior temporal quadrant. If bleeding occurred from 
the iridotomy site, then light pressure was applied to the Abraham 
lens until bleeding stopped. 

All eyes were observed for two hours postoperatively through 
slit lamp examination, Schiotz tonometry, and visual acuity testing. 
Topical dexamethasone drops were continued until the last post- 
operative visit at one week. 

RESULTS 

A total of 26 patients were presented for YAG laser iridotomy. All 
28 eyes in 26 patients had thick, brown, velvet-like irides. All but 
one eye had crypts. Postoperative intraocular hypertension was 
treated when necessary with acetazolamide (500 mg twice daily). 
Fifteen of the 28 treated eyes (54 percent) had elevated IOP at two 
hours. Bleeding occurred in 12 eyes, but was easily stopped with 
digital pressure on the lens. There were no hyphemas. Minimal in- 
flammation occurred in all eyes and was resolved with topical 


208 Plenary Session IV— Developments in Control of Blindness 

steroids. Postoperative anterior chamber inflammation was mild and 
there was no activity in any eye after the first postoperative day. 

The mean energy required for a patent iridotomy was 9.25 milli- 
joules. Most eyes had pigment present in the anterior chamber on 
the first postoperative day but not later. Bleeding occurred in six 
eyes. No corneal or lens damage occurred and all iridotomies were 
patent at one week. 

All ophthalmologists were competent at performing iridotomies 
at the end of the trial. The laser system functioned well. Forty ad- 
ditional patients were subsequently treated throughout the regions, 
but at the time of writing the system was unserviceable, apparently 
because of insufficient laser power. The one unsuccessful iridotomy 
patient, an Indian male, has since undergone filtration surgery. 

DISCUSSION 

In all eyes but one, a patent iridotomy was successfully made, with 
major complications being iris bleeding and elevated intraocular 
pressure. No visual acuity loss was noted. The follow-up time is 
now six months, and all iridotomies are still patent. 

Ten millijoules in one pulse appears to be an ideal energy level 
for successful iridotomy. Fifteen of the 28 treated eyes had a post- 
operative intraocular pressure elevation at two hours, despite pre- 
operative pilocarpine and dexamethasone. All returned to normal 
levels at 24 hours. 

There is an urgent need to collect comprehensive data on the 
prevalence of angle-closure glaucoma in Myanmar. The 7905 Nd- 
YAG portable laser system may be a valuable tool in treating acute 
glaucoma prophylactically, particularly in remote areas where there 
are few health-care professionals, but such treatment must be re- 
served for those at risk because resources are limited. As with any 
high-technology equipment it is important that adequate back-up 
be provided for this system. It is hoped that with adequate service 
facilities this laser system can be used in the prevention of blind- 
ness due to pupil-block glaucoma. 

REFERENCE 

1. Robin AL, Arkell S, Gilbert SM, et al. Q-Switched Neodymium 
YAG Laser Iridotomy: a field trial with a portable laser system. 
Arch Ophthalmol 1986;104:526-30. 


11 


Eye-Health Education 
and Social Marketing 

Dr. (Mrs.) Gopa Kothari 

There are at the very least 27 million blind people in the world and 
perhaps 30 million more with severe reduction in vision. Unfor- 
tunately, these numbers are increasing. The major blinding eye con- 
ditions in the world are cataract, trachoma, glaucoma, corneal 
ulceration (particularly associated with vitamin A deficiency and 
measles in children), onchocerciasis, trauma, and leprosy. These ma- 
jor causes of blindness have different patterns in the developing 
and developed world. Up to 80 percent of this blindness is avoidable. 
This means it could be cured or prevented within the limits of 
resources that are available in the country or region in which the 
blindness occurs. The challenge is to develop eye-health education 
and care for communities, and also to allocate resources according 
to priorities that will allow substantial reduction in the number of 
people who are blind. 

Health has to be attained, it cannot be imposed. The com- 
munication of health-education information facilitates participa- 
tion in positive community actions. The first requirement for the 
attainment of eye health is a commitment to this goal by both the 
people and the government. 

In developed as well as developing countries, there are many 
diverse economic conditions, living standards, literacy levels, 
languages, and social customs. Eye-health education activities should 
be tailored to the specific needs of the people for whom they are 
meant. This enables adequate utilization of the available resources. 
It is vital to provide education about the prevailing eye-health prob- 
lems and the methods of preventing and controlling them. This is 
the first of eight essential activities in primary health care. A new 
look at eye-health education is essential. 

In calling for new approaches to eye-health education in primary 
health care, we must recognize that no aspect of eye care is static. 


209 


210 Plenary Session IV— Developments in Control of Blindness 

To make health education more effective, it is essential to tailor the 
educational information to the prevailing lay and professional 
perceptions of eye-health problems. 

Originally, health education developed along the biomedical 
views of health and disease current at the time. Social, cultural, and 
psychological factors were thought to be of little or no importance. 
The assumption underlying health education activities was that 
people would enjoy better health if they would act in the manner 
recommended by health workers. The emphasis, therefore, was on 
the transmission of correct health information to the general public. 

Eye-health education was developed, as the outward and down- 
ward communication of eye-health knowledge to individuals with 
limited ideas on how to avoid illness or cope with diseases. In the 
early years, relatively little effort was made to understand people’s 
traditional health beliefs and practices and to consider these beliefs 
in developing health-education strategies. Although some attempts 
were made to learn what the communities themselves regarded as 
their health needs and priorities, the attempts were not systematic. 
Rather, it was assumed that only health professionals were in a posi- 
tion to assess these needs and priorities. 

Furthermore, eye-health education has been operating almost 
entirely within the value system of professional allopathic medical 
services. Its goals have been set within that framework and its 
achievements are measured in the patients’ compliance with treat- 
ment, the reduction of hazardous health habits, and the reduction 
of the period between the beginning of an illness and that time when 
the patient seeks treatment. In the past, health-care providers have 
focused mainly on the modification of individual behaviors, im- 
plying that the individual is solely responsible for his plight. This 
approach blames the sick, the poor, and the miserable for their ill- 
ness, their poverty, and their misery. It ignores the fact that in a 
number of situations it is not the individual who needs to be changed 
but the social environment in which he or she lives. The political, 
economic, and environmental factors that have a negative or neutral- 
izing effect on healthy behavior need to be modified. 

What, then, is the proper role of health education? The Direc- 
tor General of WHO has clearly outlined the areas where new think- 
ing is required: 

1. Health education needs to develop new policies in harmony 


Eye-Health Education and Social Marketing 211 

with the principles of primary health care and the strategy 
of health for all by the year 2000. 

2. Health education needs to facilitate the development of 
human resources with the skills to translate social goals into 
educational objectives for health for all by the year 2000. 

3. Health education needs to reflect on the educational 
technology most appropriate to promote individual and com- 
munity involvement and self-reliance. 

4. Health education needs to strengthen its multifaceted ap- 
proach and to increase coordination of health education ef- 
forts through appropriate technology. 

5. Health education must pay greater attention to monitoring 
and evaluation. 

From this perspective, priority must be given to the develop- 
ment of a people-oriented eye-health technology to meet the needs 
of the general population, while giving appropriate consideration 
to the needs that are recognized epidemiologically to require urgent 
attention. 

Eye-health education has a powerful new role to play in pro- 
moting the involvement of lay persons in eye-health care. The role 
will require: 

1. Reorientation of techniques and social analysis. 

2. New educational methods that aim to enable people to iden- 
tify and assess eye-health problems and to give them con- 
fidence in solving those problems. 

3. New ways of creating links between key groups in the com- 
munity and of negotiating solutions for eye-health problems. 

We must keep in mind that the rapid proliferation of community- 
based health-education programs has outpaced the knowledge base 
of behavioral change strategies that are appropriate and effective 
for public health interventions. 

Health in its widest sense can be considered as a consumer prod- 
uct. If people do not want health, they will not make an effort to 
“buy” it. Producers and sellers of goods have marketing techniques 
and approaches that are highly efficient. Can these same techniques 
be applied to selling health? 

Experiences of various programs and other public health educa- 
tion efforts, especially in the fields of population, nutrition, and 


212 Plenary Session IV— Developments in Control of Blindness 

agriculture extension have pointed to the usefulness of social 
marketing principles in formulating and implementing broad-based 
behavioral change programs. 

Social marketing represents a bridge that links the behavioral 
scientist’s knowledge of human behavior with the socially useful 
implementation of this knowledge. It offers a useful framework of 
effective social planning at a time when social issues have become 
more relevant and critical. 

The important aspects of social marketing that can be applied 
to eye health include: 

1. A program that can increase the acceptability of ideas or prac- 
tices in a target group. 

2. A process that can solve the problems using marketing 
techniques. 

3. A process that applies marketing thoughts to the introduc- 
tion and dissemination of ideas and issues. 

4. A strategy that can translate scientific knowledge into effec- 
tive educational programs by developing effective com- 
munication strategies. 

For social marketing to become successful and have durable 
results for eye-health education programs, it is necessary for the 
social marketing techniques to be based on an analysis of people’s 
wants and needs in a given area, to develop a well-conceived model, 
and for this program to appeal through mass and specialized com- 
munication media to the targeted audience. 

Today social marketing techniques for eye health need to concen- 
trate on creating awareness about various eye problems, the impor- 
tance of promoting prevention, the availability of curative services, 
and the need for effective utilization of the existing infrastructure. 
The challenge for social marketing is to create awareness, to reduce 
barriers for treatment, to make people come forward for eye care, 
and to see that they are satisfied with the treatment. This will enable 
behavioral change. 

To use this powerful and useful tool of social marketing for eye 
health, it is necessary that we are clear about: What are we selling? 
Who are we selling it to? How are we selling it? On this basis, a 
social marketing plan for eye health can be developed. 

1. What are we selling? 

Broadly we can say that we wish to sell awareness about 


Eye-Health Education and Social Marketing 213 

existing eye problem practices, reduction in eye problems, 
reduction in complications, and services or methods that can 
reduce blindness. Our aim is to sell change in behavior, 
lifestyle, and risk reduction by utilization of existing eye ser- 
vices. Demand for more eye-care services will result in im- 
provement in eye health. 

2. Who are we selling it to? 

We have to sell this to the target group who may or may not 
be able to pay for the eye services. We must supplement the 
existing government program that can result in the improve- 
ment of eye health in the target group. 

3. How are we selling it? 

We can best sell eye health through the mass media and the 
training of ophthalmologists and paraprofessionals working 
in the field of eye care. 

Advertising in television, radio, cinema, billboards, posters, ban- 
ners, newspapers, and written messages are important. The produc- 
tion of health-education materials and manuals for primary health- 
care workers and local leaders of community organizations can also 
play a very important role in increasing knowledge, changing at- 
titudes, and modifying behavior through the cumulative effect of 
health messages. 

The training of professionals and paraprofessionals working in 
the field of eye care will help them to act as facilitators of healthier 
behavior. Such training promotes the two-way transfer of technol- 
ogies between the ophthalmic system and the community. It also 
leads to the recognition of the contribution of professionals in other 
sectors. For example, environmental support can ultimately result 
in promotion of eye health. 

Social marketing principles are especially well-suited for the task 
of translating complex educational messages and behavioral-change 
techniques into concepts and products that will be received and acted 
upon by a large segment of the population. However, it is not magic 
that works in all circumstances. Even when correctly applied, social 
marketing has its limitations. Brief social -marketing campaigns can- 
not be expected to result in substantial cognitive and behavior 
changes. Their strategic and continuous application, however, is 
viewed as a necessary condition for effective public health 
intervention. 

A new approach is necessary for eye-health education to increase 


214 Plenary Session IV— Developments in Control of Blindness 

the effectiveness of individual counseling and small-group pro- 
gramming. Penetration of individual-based or group-based eye- 
health education methods into many hard-to-reach segments of the 
population and the development of programs that cause changes 
in the population with existing resources and technology will ef- 
fect such positive movement. 

As we face the worldwide increase in blindness there is a need 
to develop a comprehensive educational program that will help to 
prevent blindness through early diagnosis. This will increase the com- 
munity demand for better eye-care services. In order to achieve our 
objective we need to use multiple channels and multiple communica- 
tion methods. We need the alliance of communicators, health pro- 
fessionals, media professionals, religious leaders, community leaders, 
trade union leaders, teachers, employers, business leaders, school- 
children, popular personalities from the entertainment industry, and 
advertising and media experts to make it possible to consolidate 
the gains of each group for better eye health. 

All educational tools have shortcomings. Multiple disciplines: 
social marketing, behavioral analysis, and anthropology, which have 
significantly influenced public health communication, are therefore 
advocated. Social marketing can be the basis for health communica- 
tion of eye care. Behavioral analysis focuses on existing eye-health 
practices and identifies areas of possible change for better eye-health 
and anthropological investigations. These efforts can lead to the 
development of comprehensive eye-health education. A promotional 
program for eye care thus keeps in mind consumer’s needs, prac- 
tices, and preferences. 

Public health communication provides a strategy for planning 
and conducting long-term eye-health education programs that can 
enable people and communities to make their own decisions on the 
matters of eye health. Whereas creating awareness through social 
marketing may be a step in the right direction, behavioral analysis 
and anthropological investigations should initiate the cyclical nature 
of the process. The programs developed should result in the increase 
of knowledge regarding eye care, mobilization of the resources, and 
the development of the community participation needed to con- 
trol eye problems. We hope that all of this will ultimately result in 
the reduction of the number of visually handicapped and blind 
individuals in the world. 


12 


Management Issues in 

Primary Eye-Care Training Programs 

Ms. Victoria M. Sheffield 

Programs must be planned properly before the training actually 
begins to avoid delays and additional costs. 

A primary eye-care training program should address: design, 
staffing, time, costs, curriculum and materials development, and 
monitoring and evaluation. 

A needs assessment should address: the most common eye con- 
ditions, the location and aptitude of available health personnel, the 
facilities available for training, the identification of the trainers, 
and what the health workers are allowed to do by law. 

Planning is essential and at least one fourth to one third of the 
project’s entire time should be devoted to planning government 
agreements, conducting meetings with all appropriate counterparts, 
designing and field testing training materials, and preparing for un- 
foreseen difficulties such as floods, strikes, and political unrest. 

Materials for various levels of staff should be prepared. For the 
administrators or policy makers, a document such as the WHO’s 
“Strategies for the Prevention of Blindness in National Programmes” 
is excellent to inform these people of the reason and need for training 
health workers in eye care. At the tertiary level, ophthalmologists 
may profit from information of a public health nature so they 
understand the impact of blinding diseases on the population-at- 
large. At the secondary level, more technical information is ap- 
propriate. And at the primary level, you will usually have to use 
the local language to prepare appropriate materials especially for 
the health workers. 

An extremely important consideration which must be made at 
the beginning of the program is that of motivation. If you are go- 
ing to train health workers to perform additional duties, what will 
be their incentive? Often, it is recommended that graduates be 


215 


216 Plenary Session IV— Developments in Control of Blindness 

upgraded or moved up for consideration for promotion, which in 
turn rewards a raise in pay. 

Ophthalmologists may not be the best trainers. Whereas health 
educators, especially those with eye-care experience, are ideal. 
Trainers need to know other methods such as demonstration, prac- 
tice, role playing, and how to use the audiovisuals. 

You need to find suitable training facilities. Comfort and room 
size are extremely important, especially in the afternoons in hot and 
humid climates. Electricity is necessary if you want to show slides 
or videos. A hotel is often a good place because it usually has a 
hall, which may be used as a disco at night. Of course, the hotel 
can also accommodate the trainees with room and board during 
the seminar. 

Concomitantly with the above, appropriate training materials 
must be designed, field tested, and produced. This requires good 
writers and artists. There must be film-developing services available 
if you are to produce slides depicting local conditions. What are 
the printing services available so that materials and posters can be 
produced locally? Most importantly, you need to have enough time 
to field test your materials with the target audiences and make 
necessary revisions. You must consider future needs for materials 
and the availability of services to produce additional supplies. 

To know how well your program is performing and impacting 
on the problems being addressed, a monitoring and evaluation plan 
must be included from the very beginning. With regard to the 
trainees themselves, pre-and post-tests are valuable to determine 
what they have learned in the training. A post-test can be given again 
after six months or one year to determine if the trainees have re- 
tained the information they have learned. 

Trainees should be taught how to correctly record their findings 
in an eye exam, especially if the patient needs to be referred. Addi- 
tionally, trainees should be taught how to properly report their 
activities to their supervisors on a scheduled basis, either weekly, 
monthly, or quarterly. This information can then be analyzed to 
determine many factors such as patient usage of clinic services, 
numbers of patients seen, treated, or referred. A training program 
should understand how health workers are supervised, and such 
information should be included in the program and used especially 
to instruct the trainees about reporting. Because continuing educa- 
tion is important, a plan for this should be included in any train- 
ing program. 


Issues in Primary Eye-Care Training 217 


Do not raise expectations. Health workers should be trained to 
do what is appropriate for their level and what is allowed by law. 
If they are trained to do more than is appropriate for their situa- 
tion, they will become frustrated and lose interest in eye care. 

Training must fit the actual practical situation. Health workers 
who are trained in a similar environment to their own working con- 
ditions and with similar resources will be able to practice what they 
have learned. This will help build confidence and competence. 

How we can look at what should be taught. A common defini- 
tion for primary eye care is basic care for common eye infections, 
first aid for eye injuries, and the public health measures that pro- 
mote and maintain general good health, such as hygiene and sanita- 
tion to prevent ocular infections, nutrition to prevent vitamin A defi- 
ciency, and safety to prevent ocular injuries. 

We can ask if primary eye care is ophthalmology. What about 
blindness prevention, is it ophthalmology too? We teach health 
workers to recognize when something is wrong. Important tasks 
for health workers include: knowing how to recognize a problem, 
deciding whether to treat or refer, and teaching prevention. 

The five rules for a normal healthy eye are: the cornea should 
be clear, the pupil should be black, the white part should be white, 
the eyelids should open and close properly, and the patient’s vision 
should be normal. 

The following format should be followed: cataract should be 
referred, conjunctivitis can be treated and prevented, trachoma can 
be treated and prevented, xerophthalmia can be treated and 
prevented, injuries can be treated and prevented 

Health workers must be taught the following basic skills: how 
to perform an eye examine, how to measure and record visual acuity, 
how to evert an eyelid, how to apply drops and ointment, how to 
make and apply an eye patch and protective shield, and how to 
remove a foreign body from the eye. 

Eye-care workers often do not make the connection that public 
health measures can also prevent blindness. They must understand 
these principles when talking to community groups about blind- 
ness prevention. Important groups to target for these activities in- 
clude: women’s groups, schoolchildren, church groups, social clubs, 
professional clubs, and the general public during mass screening 
campaigns. Social marketing techniques can be employed to en- 
courage people to expect and demand eye-care services and even 
to know how to prevent their own eye problems. 


218 Plenary Session IV— Developments in Control of Blindness 

Again, hygiene and sanitation prevent ocular infections. A 
balanced diet and food preparations for infants that include vitamin 
A prevent xerophthalmia. In addition, safety education can pre- 
vent ocular injuries. 

Messages can be disseminated through the use of the radio and 
newspapers. Posters and pamphlets work well if your program has 
the time and resources to produce these appropriately. 

And lastly, we must always remember about appropriate 
technology. Whatever we do must be appropriate for the audience 
being trained or targeted. 


PART 6 


PLENARY SESSION V 

Sustainable 

National 

Program 

Development 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 






1 


Starting a National Committee 
for Prevention of Blindness 

Dr Lincoln Agaba 

Be it religious, political, or health-related, establishing any sus- 
tainable national program is a herculean task. One major hurdle, 
especially in the developing world, is the need to justify the com- 
mitment of limited resources to a prevention of blindness program. 

Although obvious to an ophthalmologist trained in primary eye 
care, it can be confusing to an uninitiated ophthalmologist. It is 
the duty of trained primary eye-care workers to explain to their col- 
leagues as well as to the Ministry of Health why a national com- 
mittee is essential. Failure to gather enough facts can result in the 
failure to convince the administrators of the necessity of forming 
another body in the Ministry. In addition, budgetary constraints 
amplify this problem. The fact that your program will eventually 
be cost-effective must be made clear and supported with facts. It 
is important to note that the meager budgets of ministries of health 
range between 2 and 5 percent of their national budgets in some 
developing countries. 

The facts need to be made tangible, and eye workers should be 
the demonstrators. Opening a dialogue with the Ministry of Health 
is a good first step. The Director of Medical Services and his deputies 
must be given adequate exposure to understand that blindness is 
a problem that can be solved with primary eye-health programs 
under the auspices of a national committee for the prevention of 
blindness. Friendly local and international NGOs should be con- 
tacted and told that their contribution may ease the pressure from 
the Ministry of Health. Their experience or a promise of financial 
assistance can be very helpful. 

The director or senior deputy of medical services should be con- 
vinced to take the chairmanship of the committee and the patron 
should represent the Ministry of Health. This way, the committee 
is in communication with the top officers of the Ministry. In other 


221 


222 Plenary Session V— National Program Development 

words, you need a friend in the top echelon of the Ministry of Health 
to understand your language. We, on the other hand, had to sit down 
as eye workers in the Uganda Foundation for the Blind to write up 
a document to market and sell the prevention of blindness program. 

Loopholes left in the document will upset government planners, 
who are usually not eager to have new programs. In Uganda these 
political machinations took three years to become effective (from 
1983 to 1986). A Minister with good insight into the problem listened 
and inaugurated our committee in February 1986. 

A document, the content of which should be broad, needs to 
be prepared. Other ministries should be involved in making deci- 
sions concerning the committee’s formation and funding. Demo- 
graphic data (population, age, and sex distribution) are vital in both 
urban and rural areas. These statistics are important because blind- 
ness is directly linked to these factors. 

The document should be clear about national health-care 
systems. Government health policy, structure, the role of govern- 
ment in health care, and the involvement of universities and medical 
schools should be laid out without ambiguity. We were sent back 
several times to consult with such institutions. 

Other points to consider include the magnitude of the problem 
of blindness, the major causes of blindness, the possible sources 
of funding, and the objectives that are long-term (reduction of blind- 
ness to 0.5 percent by the year 2000), medium-term, and short-term 
(relevant training programs for eye workers) with recommendation 
of measures to achieve them. 

I must say that Sight Savers, WHO, and our local Uganda Foun- 
dation for the Blind were instrumental in the inception of our com- 
mittee. After our establishment, Christoffel-Blindenmission con- 
tributed greatly to the committee’s efforts. Funding for training, 
the backbone of marketing the committee’s new philosophy, was 
a major priority for the National Prevention of Blindness Com- 
mittee. Outreach, research, cheap eye drops, and glasses were also 
effective ideas to show government planners. 

The committee must be a multidisciplinary one. It cannot be 
for eye people alone. The health inspector and the district agricul- 
tural officer are important players in the prevention of blindness. 
We approached them as we fought for the committee to be 
established. 

Let me illustrate the bureaucratic problems of one of our ma- 
jor projects. We decided to start a school for ophthalmic clinical 


Starting a National Committee 223 


officers. We wrote to the authorities on July 22, 1986. The reply 
came on January, 27, 1987, and read as follows: “I refer to your 
letter of July 21, 1986, and regret the delay in replying. This was 
due to the rather slow process in consultation of the matter. The 
Director of Medical Services responded while I was on leave, thus 
the delay. We have now come to the agreement that we would need 
to draw complete training proposals for submission to the Public 
Service Commission and Finance for approval before we embark 
on the training. This is based on the past experience of training 
cadres without approved titles and posts and then failing to appoint 
them. The result was frustration, and the trainees abandoned the 
new skill for their original positions. It would be unfair if we did 
not learn from that mistake. Besides, we prefer to conduct full 
Diploma courses in preference to ad hoc programs. 

“I am now inviting you to bring a detailed proposal stating title, 
entry requirements, training period, entry point to service, salary, 
promotional avenues, numbers per year, and justification for fur- 
ther discussions with our Personnel Division and eventual submis- 
sion to Public Service Commission.” 

These are late but fair questions of which the committee must 
be aware. The answers were submitted. Public Service came and we 
had discussions. The Permanent Secretary wrote a letter to the Min- 
istry of Health on the 9th of June, 1988. The Finance Ministry con- 
firmed on August 22, 1988. 

This ping-pong continued but we finally succeeded in impress- 
ing upon the government the role of the committee and the necessity 
for its formation. A proper incremental salary system after gradua- 
tion was agreed upon. Other paramedical workers often start without 
this benefit. Without it they might have gone back to being general 
Medical Assistants, deserting the new job. 

The three ministries also agreed on a promotional ladder for 
ophthalmic clinical officers that rewarded diligent performance. Pro- 
motion to senior ophthalmic clinical officer grade II and later to 
grade I as a ceiling level, with a salary the equivalent of a doctor’s, 
is possible. 

The school eventually started in 1989 and RCSB agreed to fund 
this school with some support from the government. We are grateful 
to RCSB. May I mention Mr. Alan W. Johns, Mr. Paul Streets, Mr. 
Kevin Carey, and Dr. Randy Whitfield for their tireless efforts. 

The negotiations with the government took months. One must 
go to the Ministries of Health, Planning, Justice, Finance, and Public 


224 Plenary Session V— National Program Development 

Service for clearance to sponsor a school. When this project finally 
got started the committee’s morale improved. We are now called 
upon to chair and advise the onchocerciasis committee, the trachoma 
committee, and others. 

Our committee is now in the forefront of onchocerciasis, 
trachoma, and cataract programs, advising the patron and the Direc- 
tor of Medical Services of shortcomings, but funds remain a prob- 
lem. Procuring eye drops and inexpensive glasses is still a big chal- 
lenge to the committee. With assistance from the WHO and other 
departments of the Ministry concerned with primary health care, 
outreach work is beginning mass mobilization. 

Mr. Chairman, the strength of the committee will depend largely 
on constant pressure from their members and clearly researched pro- 
grams. With these two elements the committee will not fail. 


2 


Raising Funds to Develop 
a National Program 

Dr R.P. Pokhrel 

The national program of blindness in any country depends upon 
the leadership of the program manager, the basic infrastructure, 
the commitment of decision-makers, good communication and 
coordination between the appropriate bureaucrats and professionals, 
and active community participation. The success of such a program 
requires the leadership to be dedicated, to have powers of persua- 
sion, and to possess in-depth technical knowledge with a clear 
conception of the goals of the program. It will also require the team- 
work of a few dedicated social workers and professionals who 
understand their society and their government. You have to work 
very hard to motivate the decision-makers and the community 
leaders to convince them; but once they have developed confidence 
in you, you will get all the support you need. 

When I returned back to Kathmandu in 1971 after my training 
in England, I was a very junior surgeon posted in an eye depart- 
ment in a general hospital in Kathmandu. I had very little private 
practice and I had to go in remote areas with mobile eye camps 
visiting various rural areas and meeting people, community leaders, 
and social workers. This activity gave me tremendous exposure to 
the socioeconomic conditions of the country and an in-depth 
knowledge of the problems of blindness which inspired me to start 
a separate eye hospital with public support. 

I worked hard talking to social workers, various NGOs, lawyers, 
industrialists, and the professionals in the field. I also started writing 
articles convincing the people through local newspapers. Eventually 
I was able to organize a group of dedicated social workers to form 
a committee to launch the Nepal Eye Hospital. I had several ob- 
stacles, first from my own ophthalmic colleagues, then the Ministry 
of Health, but without offending them, I started working single- 
handed on this program during off periods. I even donated all of 


225 


226 Plenary Session V— National Program Development 

the basic eye instruments and equipment, because in the beginning 
I had to start everything from scratch. 

I would like to share with you some of the experiences one might 
have while operating such an eye-care program. When you start the 
program, people will not know you first, so they will not have con- 
fidence in you. Unless there is confidence, you will not get their 
support; and until you win the backing of the people, the govern- 
ment, or sources of external funding you cannot run the program. 
Everybody will just watch you to observe your dedication, sincer- 
ity, technical capability, behavior, and the society you move in. You 
have to prove that you are sincere in your profession, dedicated in 
your service, and trustworthy in your accountability. Many so-called 
social workers in the past have taken donations from the public and 
have misused the money. Therefore, because people will be very 
careful and watch every step, it is important to keep the organiza- 
tion’s reputation spotless. Regular progress reports, annual auditing, 
effective communication, and assiduous dedication will win con- 
fidence in the program both internally and from the outside world. 

Regarding the eye-care services, you do not need advertising but 
rather a competent and sincere approach. You must consider each 
patient, whether rich or poor, as an ambassador of your program. 
If he or she is impressed by your organization, he or she will convey 
a positive message to the community. Therefore, the selection of 
correctly motivated staff is very important for the success of 
your program. 

Blindness prevention and control programs in many develop- 
ing countries are often planned and initiated with foreign support. 
To avoid continuing dependency on foreign assistance, each program 
should try to generate its own income from the very beginning so 
that it can sustain its services even after the foreign support has 
been withdrawn. 

The success of income-generating activities will be dependent 
upon hospital location, the economy of the country, the regulations 
of the government, the effectiveness of the local prevention of blind- 
ness society, and the hospital management. 

SELF-SUFFICIENCY 

To reach self-sufficiency two main principles have to be worked out. 
The first is to maintain operating costs at a minimum from the very 


Raising Funds 227 


beginning, and the second is to develop successful income-generating 
activities wherever possible. Keeping operating costs low will pro- 
vide savings and income-generating activities will give you earn- 
ings and means of continued support. Now let us see how we can 
save on the operating costs. 

1. Staffs: Engage a minimum number of highly qualified staff. 
Give preference to the local staff, and train them according 
to the needs of the hospital needs. It is preferable to train 
them within the country, or at least within the region, and 
utilize them as multipurpose hospital workers. 

2. Relatives of patients: Involvement of patients’ relatives in pa- 
tient care minimizes the need for hospital nursing staff and 
guarantees better food preparation and better care for the 
patients. 

3. Equipment and materials: Use locally available materials for 
preparing swabs, eye pads, bandages, OR table, beds, etc. 

4. Appropriate technology: 

• Self prepared suture: a piece of 8/0 silk which is threaded 
through an eyed corneal needle. The needle can be reused 
hundreds of times. 

• Sterilization of cataract sets and newly prepared sutures 
in a domestic pressure cooker. 

• Simple freon-cryo system: one kilogram of freon costs $3.50 
and lasts for about 1,000 cataract extractions. 

5. Maintenance: Sharpening of cataract knives, needles, scissors, 
other surgical equipment, and instruments can be done by 
hospital staff without sending them outside. 

6. Use of building materials: Wherever possible locally available 
building materials should be used for hospital construction 
and the hospital should be designed in such a way that the 
maintenance costs are kept to a minimum. 


INCOME-GENERATING ACTIVITIES 

In most developing countries, because there is no health in- 
surance to cover medical treatment, the majority of patients can- 
not afford the costs of modern medicine. Patients who are able to 


228 Plenary Session V— National Program Development 

pay should pay for treatment, but those who are unable to pay the 
full costs should pay what they can or even receive their treatment 
free of charge. However, we should encourage patients to pay even 
a small amount. 

Income-generating activities of the hospital are as follows: 

1 . Charging for services: These might include costs associated 
with registration, refraction, special investigations for glau- 
coma, visual field examinations, retinal examinations, and 
pathological services. 

2. Selling eye medicine: One can buy medicine at a wholesale 
price and sell it at a retail price. This practice, which could 
return a profit as high as 16 percent, will cover the costs 
of the medicine given to those patients who are poor and 
will not be charged full price. Another advantage is that 
we can be sure that the patients will receive the correctly 
prescribed medicine and the patient will be taught how to 
apply those medicines correctly. 

3. Charging for surgery: The cost of a cataract operation 
should not exceed the minimum basic salary earned in two 
weeks by the individual. The cost of the operation should 
include spectacles and eye drops and should be a fixed 
amount. The patient should be made aware of this cost and 
be asked to save that amount of money before he or she 
visits the hospital for surgery. 

4. Charging for private rooms: Private rooms with better ac- 
commodations will encourage people with high incomes to 
patronize their own country’s hospitals for surgery; this will 
help stop the drain of the country’s economy to neighbor- 
ing countries. Although those who cannot afford to pay 
should be treated free or at a nominal cost, the quality of 
the service should be the same for all individuals. 

5. Farming activities: If the hospital is located in rural areas 
and if it owns sufficient land, one can generate income by 
selling fruits, such as bananas, pineapples, mangoes, litchi, 
papayas, and medicinal plants cultivated within the premises. 
In addition, bee-keeping, agro-farming, and tree planting 
can generate income, which has been tried in various centers 
of Nepal. 

6. Leasing hospital shops and other accommodations: If the 


Raising Funds 229 


hospital invests capital in developing its own hospital, for 
example in constructing a shopping arcade or other accom- 
modations to sublet, there is a good chance for regular 
income. 

7. Eye-drop production and local manufacturing of spectacles: 
Local production of glasses will help train paramedicals and 
generate income for the hospital; and, if incentives are given 
for the sale of these glasses, it will help promote business. 
The production of local eye drops on hospital premises will 
help to support hospital patients whose treatment will be 
subsidized. During eye camps this production will generate 
income for operating the hospital. In addition, this freshly 
prepared medicine will be available for the needs of the 
patients. 

8. Production of IOLs: Patients in developing countries can- 
not afford to pay for costly IOLs produced in developed 
countries. However, if it is within their range, most patients 
in developing countries can afford to pay such a cost. In 
recent years patients have demanded such surgery and have 
told the surgeons that they want to keep the optical correc- 
tion inside the eye. Moreover, they have been willing to pay 
whatever money they can afford. This may be true in other 
countries as well. Because there is a growing demand for 
IOLs, there is a need to establish an IOL factory in Nepal. 
This, I hope, will generate some income to support the 
hospital, if the management and quality control are done 
effectively. 

9. Investment in real estate: Take the advice of your legal coun- 
sellor and discuss investment possibilities with the managers 
of your bank and other colleagues. You might consider in- 
vesting part of the savings in a fixed deposit that could yield 
up to 13 percent per year, which often is tax free for philan- 
thropic organizations, or you could invest in property where 
there is usually an annual increase in prices. 

10. Family Trust: The country may be poor but in each nation 
there are few individuals who are rich and want to main- 
tain the name of their families by donating some property. 
Such donations can be a cash or a building or a plot of 
valuable land. The donors should receive adequate recogni- 
tion from the public and from the government. Perhaps they 


230 Plenary Session V— National Program Development 

would like to make their donation in memory of one of their 
departed family members. Some families create a family 
trust and through that trust build the physical facilities, ac- 
cording to your advice. In addition, some will also bear the 
necessary expenses for the day-to-day operating costs. 

In Nepal, the government has provided us with a huge 
plot of land for tree plantation and has also donated some 
very valuable land for the construction of a hospital. Dur- 
ing the transfer of the property, they have waived all of the 
taxes for the organization. Two families have built 50-bed 
eye hospitals and are bearing the necessary expenses for the 
operating costs at the Golccha Eye Hospital and Kediya Eye 
Hospital respectively. 

The Choudhary family has donated the very valuable 
land at Lahan and the hospital is named the Sagarmatha 
Choudhary Eye Hospital. Rana Bahadur Shah has donated 
land at Bhairahawa to build the Seva Eye Hospital and is 
going to donate $35,000 as a fixed deposit to meet some 
of the operating expenses. Similarly in Nepalgunj a very rich 
old person donated land and a beautiful building for the 
Fateh Bal Eye Hospital. Now many individuals are coming 
forward to donate their properties and to bear part of the 
operating expenses in cash invested as a fixed deposit. So 
far the Nepal Eye-Care Program has been able to generate 
$2.0 million in cash and $5.3 million in-kind through dif- 
ferent individuals, social organizations, and the govern- 
ment-all within a period of 10 years. 

11. Personal Contact: People’s confidence on your leadership 
and positive recommendations by your patients and col- 
leagues is important. A good project proposal and the sup- 
port you receive from your government will also help to raise 
funds from various international organizations supporting 
eye-care activities. Some organizations may like to support 
training, others to clear the backlog of cataract, or to es- 
tablish a trachoma program or a vitamin A program. A few 
may wish to support a physical plant or other facilities. You 
have to fit in those organizations according to your need 
without duplicating the services. Let individual organiza- 
tions work independently under your supervision and 
guidance, according to your need. 

Treatment of a dendritic ulcer and a support of a 


Raising Funds 231 


satisfied patient brought me in contact with Operation 
Eyesight Universal, Canada. An eye camp and the recom- 
mendation of a German orthopedic surgeon brought me in 
contact with Christoffel-Blindenmission, Germany. The per- 
sonal initiative of a Japanese surgeon working in mobile 
eye camps brought us in closer ties with Japan and then 
subsequent support for equipment and training. A dedicated 
Dutch ophthalmologist through a mobile eye camp brought 
about Foundation Eye-Care Himalaya, followed by eye-care 
programs in Gandaki and Dhaulagiri Zones. The most im- 
portant thing in the program is your own initiative, dedica- 
tion, and personal contact through various channels. 

I would like to recapitulate a brief discussion during 
lunch at the WHO cafeteria in New Delhi with Dr. Nicole 
Grasset in 1978. That brief chat, which gave birth to the 
Nepal Blindness Program, also led to the national survey, 
training of manpower, the effort to clear the cataract 
backlog, and subsequent continued support from Seva Foun- 
dation, USA. Seva is the organization that is supporting not 
only our comprehensive eye-care program in the Lumbini 
Zone but has supported the establishment of the national 
program, health education and manpower planning, research 
and evaluation, and the program that allows Nepali 
ophthalmologists to attend various international conferences 
and to present various scientific papers. 

My contact with Prof. Hollows from Australia as an STC to 
the Nepal Blindness Program has resulted in the Nepal Eye-Care 
Program, Australia. Through this program some ophthalmologists 
and paramedicals have received training in Australia. And, lastly, 
the support of the British Council has been most valuable and 
substantial in helping us to train our technical manpower. 



3 


Major Challenges and Priorities for the 
Delivery of Eye-Care Services 

Mr. K.S. Gupta 

The two most common challenges encountered in developing coun- 
tries today are poverty and illiteracy. Both these factors directly con- 
tribute to the ever-growing problem of blindness. The devastating 
fact is that in India, where there are over 600,000 villages, at least 
12 million people are blind. About 82 percent of this blindness per- 
tains to cataract and cataract-related disorders that can be cured. 
About 1.4 million are able to have their eyesight restored through 
the efforts of NGOs and government agencies. And a rough estimate 
shows that about 6 million are added every year to the already huge 
backlog of blind people. This is alarming, and the task is a daunt- 
ing challenge. 

Let us take a look at a typical village in India. Such a village 
is generally located very far from any major health center. Thus, 
I will not be wrong in assuming that in any given village only a 
small percentage of people will have access to health care or a 
doctor — usually by virtue of his or her being in an economically 
better situation than the others. The rest of the population who 
are unfortunate, have to fend for themselves. This means that, if 
any health or eye problems arise, they will first try their own home 
remedy or go to a “quack” located in the village. Gradually they 
will become dependant on others because of their prolonged 
sickness, and finally they will die a miserable death. Is this what 
humanity is all about? We, at Lok Kalyan Samiti therefore decided 
to go to the doorstep of these villagers and provide what medical 
relief we could in our own small way. 

Lok Kalyan Samiti has taken up the program of prevention of 
blindness and directly works in the area of cataract cure. LKS has 
so far performed more than 17,000 eye operations. We have been 
able to operate with a success rate of nearly 99.9 percent over all 
these years. 


233 


234 Plenary Session V— National Program Development 

Our priorities are: raise funds, allocate funds, select villages, 
screen people, and provide a high level of health-care service. 

Now to elaborate on each: At one time India had only very rich 
and very poor people. Today there is a large new middle class that 
has been growing at a very high speed and has a fairly large 
disposable income. We at LKS have approached this middle class 
to collect funds because these people see the problem on a one-to- 
one basis and are more willing to part with their money. 

This middle class is made up of people who are easy to approach; 
they respond favorably to a good cause and derive satisfaction at 
the thought of sharing their money with their poorer brethren. At 
LKS we thus make them partners in our fund-raising drive. These 
are often people who have also seen or experienced poverty at some 
stage in their own lives. 

When you approach the higher income groups, the response is 
totally different. Apart from viewing with suspicion the whole cause 
you are representing, they ask you to return again and again until 
you either give up, or they finally decide to contribute a small 
amount, just to get rid of you. This becomes a frustrating exercise, 
and often all of the enthusiasm with which our LKS fund-raising 
exercise began vanishes outside these palatial houses. Therefore, we 
have learned to avoid these people on the top income group. 
However, we do have some donors from this group who have heard 
of us and come forward to donate directly. But this forms a very 
small percent of our donations. 

After the funds are raised, we must budget and allocate them. 
First, eye operations are given priority and a certain sum is put aside 
for this. The balance of funds are allocated for other health-related 
programs undertaken by LKS. 

As a parallel exercise, LKS’s social service teams visit nearby 
villages and create short lists of the most needy cases to be taken 
up for the forthcoming batch of eye operations. Subsequent to this, 
LKS’s medical van revisits these listed villages to select people on 
a priority basis for the operations. 

After this, from the time they are brought to the eye hospital 
to the time they are discharged after the operation they are given 
excellent medical and personal attention. Though these services at 
LKS are totally free for them, they are treated on par with other 
patients who are treated in class A hospitals. 

Thus the entire process goes on endlessly. And every stage 
proves to be a new challenge. However, LKS has its own limitations 


Delivery of Eye-Care Services 235 


at any given time. We could have taken on a much larger number 
of patients, if we had been willing to compromise the quality of 
services offered. But we have preferred to concentrate on extending 
the best service to the number of patients that we are able to take on. 

The general belief is that anything that comes free, must be of 
substandard quality. We at LKS wish to correct this impression. Any 
person who visits the LKS hospital will see that there is no 
discrimination between the rich and the poor. They are all treated 
as equals. We have made all our patients and donors partners in 
our program. 

We do this by involving them in the whole process and by keep- 
ing them informed. They then feel good about our cause, and often 
they become our spokesmen in their own villages. But we do not 
force our views upon them. Not only do they become our partners 
in fund raising, they also feel responsible to take care and extend 
the facility to the rest of the unfortunate ones living in their villages. 
Thus they instill confidence in the minds of others who have not 
heard of LKS and are frightened of visiting any medical institu- 
tion. Although we do not claim anything on our own, the good 
work that is accomplished speaks for itself. 

The entire cost of restoration of eyesight and productivity as 
well of a person costs Rs. 500. But we are asking our donors for 
only one fifth of this, Rs. 100 per operation, because we do not 
want to ask for an amount that is too much. As far as international 
fund raising is concerned, we have been receiving funds from several 
well-known agencies. Operation Eyesight Universal (OEU), of 
Calgary, Canada, has been giving its full support since 1979. Our 
quantum leap towards self-sufficiency would not have been possi- 
ble but for the support of the OEU. Besides these agencies, we have 
been getting support from other well known clubs like Rotary, Lions, 
and various trusts, associations, and individuals in India. We are 
now meeting 80 percent of our total costs from the funds raised 
within India. 


FINDING DONORS 

The majority of our donated funds is raised by way of direct mail. 
Apart from formulating lists of donors ourselves, we seek the help 
of various automobile associations and other clubs and prestigious 
institutions in India. Then we send our complete package directly 


236 Plenary Session V— National Program Development 

to them, using his of her personal name, along with a form for dona- 
tion and a postage-paid envelope. The total cost of this mailer comes 
to Rs. 1.70 inclusive of postage. This is mailed to more than 250,000 
people a year. Our past record shows a return rate of 3.5 percent. 
This is by no means small because the mailer is sent only to new 
potential donors. 

The other source of funding is our advertisements, which are 
placed in national magazines like Reader's Digest and India Today 
on an as-needed basis. In addition, many advertisements, including 
a coupon that can be cut out and sent with a cheque, are published 
free of charge. 

The last method is through word of mouth, either by the 
beneficiary or by the donor himself. Once the donor has been made 
a partner in the process of fund raising, he or she begins to enlist 
more people in the support of LKS. 


SUSTAINING THE DONOR 

We keep in touch with our donors on a regular basis, on average 
18 times a year. How do we accomplish this? First we send him 
or her the direct mailer. When we receive the contribution, we send 
a receipt. Then we reach him or her 12 times a year through our 
newsletter and then also through our various cards for holidays like 
Diwali, Holi, New Year, and Independence Day. Thus, we are in 
constant touch with our donors; and do not give them a chance 
to forget us. 

The average expenses for each person is only Rs. 38 inclusive 
of printing and postage, whereas our average rate of return per per- 
son is as high as Rs. 300. Because we firmly believe in the slogan 
“out of sight, out of mind,” we want LKS to be in focus at all times 
in the eyes of our donors as well as beneficiaries. 


4 


The Importance of Government 
Commitment in Developing 
a Sustainable National Program 

Dr Francisco Contreras 

The National Health System in Peru has created six specialized in- 
stitutes, including National Institutes of mental diseases, neurology, 
children’s diseases, cancer, rehabilitation, and ophthalmology. 

Therefore, diseases and disorders of the eye constitute a signifi- 
cant priority of the government. The National Eye Institute of Peru 
is situated in the poor section of Lima. The Institute has 60 beds, 
four operating rooms, one Experimental Surgical Unit, an Ocular 
Pathology Laboratory, an Ocular Microbiology Laboratory, an Eye 
Bank and the usual specialized clinics. There are 22 ophthalmologists 
and 24 medical residents in the three-year postgraduate program, 
half of whom are from foreign countries. 

Each day the Institute conducts about 300 consultations and 
perform 30 eye surgical procedures. The annual budget for the In- 
stitute, which is provided by the National Government is about 
$200,000. An additional equal amount of money comes from pa- 
tient revenues and also from the contributions of non-governmental 
organizations for specific projects. 

Besides the clinical and surgical activities that I have already 
mentioned, we have a Department of Education of Medical and 
Para-medical personnel. The Department of Clinical Research and 
Publications produce a specialized biannual journal and two 
bulletins, one for ophthalmologists and the other for the ocular 
health community. The Department of Community Services includes 
assistance to slum areas, orphanages, asylums, jails, and remote 
areas of Peru. 

Peru has a National Prevention of Blindness Committee, con- 
sisting of delegates from the Ministries of Health, Education, Labor 
and from other local, national, and international non-governmental 


237 


238 Plenary Session V— National Program Development 

organizations such as, OPELUCE, CERCIL, Rotary, Lions, Helen 
Keller International, Operation Eyesight Universal, and Project Or- 
bis. This Committee is mainly dedicated to coordinations of preven- 
tion of blindness activities. 

The Peruvian National Eye Institute is giving special attention 
to the integration of the Eye Program activities with those of the 
National Health Program. We are already initiating this activity in 
selected regions of my country. 

The challenge is huge, but we have the cooperation of the 
National Government, the prevention of blindness community, 
and those in the ophthalmic professions, particularly young 
ophthalmologists. 


5 


Why Governments Commit Themselves 
to Starting an Eye-Care or Prevention 
of Blindness Program 

Dr Fiisun Sayek 

There are several reasons why government leaders start programs 
to treat or prevent blinding eye diseases. 

When morbidity and mortality related to eye diseases are high 
in a particular country, government decision-makers often commit 
the nation to finding ways of reducing them. Sixty years ago the 
newly founded government of Turkey decided to start a trachoma- 
control program to reduce the extremely high prevalence of blind- 
ing trachoma in the country. This vertical program has achieved 
its goal. Trachoma cases have been reduced dramatically in a 
short period, but this successful program has never become a 
national eye-care program or been integrated into the country’s 
health-care system. 

Decision-makers may recognize that the eye-care services are not 
well organized. Overcrowded outpatient departments, a high com- 
plaint rate from ophthalmologists, and continual public criticism 
are all strong motives for government action. 

Political leaders and administrators can be inspired by interna- 
tional organizations, particularly NGOs. These organizations can 
create incentives at different levels. 

Finally, inspiration may come from an enthusiast to whom the 
government responds. 

All or some of these four incentives may occur simultaneously, 
but just one of them can be enough motivation to start an eye-care 
program. In Turkey all happened at virtually the same time. 

After a government has committed itself to founding such a pro- 
gram, the question to be answered is: How should an eye-care 
program be started? 

In Turkey the Ministry of Health was the ideal government office 


239 


240 Plenary Session V— National Program Development 

to begin such a program, because it is responsible for planning and 
implementing health policy and is the main health-care provider. 

However, if an action-oriented program would be more suitable 
than a unit-oriented program, an existing administrative structure 
to coordinate the activities can be used. We decided to use the 
trachoma unit as our secretariat, and the Higher Council of Health, 
an advisory body to the minister, was supplemented with a special 
eye section to act as a temporary National Eye-Care Committee. 
The composition of this committee was not ideal, but it was hoped 
that subcommittees would be formed when necessary to increase 
its success. 

Some obstacles and solutions regarding the founding of an eye- 
care program are as follows: 

Often the leadership and even unit coordinators may be located 
at a distance from the program’s activities. In addition, because in 
many countries health, curative, and preventive service teams are 
organized within different departments, the cooperation between 
these departments can be inadequate. To avoid friction between 
preventive, curative, and rehabilitative programs, the coordinator 
was placed in the General Directorate of Curative Care, whereas 
the secretariat was in the General Directorate of Primary Health 
Care. Our experience has shown that this has facilitated interpersonal 
and interdepartmental interactions and has resulted in improved 
coordination. 

However, if a committed chairperson is not present, the best in- 
tentions of the government will not be sufficient. The chairman 
should be an ophthalmologist, ideally one with special training in 
public health. The coordinator’s enthusiasm, ability as an admin- 
istrator, and knowledge of the country’s health sector are vital for 
a successful start. The chairman should be a full-time member of 
the Ministry of Health, but should be able and willing to take on 
additional responsibilities. Although this may reduce the time they 
can devote to the eye-care program, it also will keep them informed 
about other health-care programs and may facilitate the integra- 
tion of beneficial eye-care activities into other programs. 

There are two additional, very sensitive points here. The first 
is that the coordinator should be able to exercise power without 
becoming bogged down in bureaucratic details. The second point 
is that they should not forget that the first priority is to run an 
excellent eye-care program. To be overly conscientious of other ad- 
ministrative priorities within the Ministry might hinder eye-care 


Why Governments Commit Themselves to Eye-Care 241 

activities. However, this should not prevent them from trying to inte- 
grate eye-care activities into the government’s other priority pro- 
grams. The coordinator also should be strong enough to handle 
the criticism of ophthalmic colleagues concerning any perceived 
delays in the eye-care program as well as possible criticism from 
other health-program managers concerning perceived fanaticism in 
the furthering of eye-care programs. 

Political instability in the Ministry may be a difficult problem 
to overcome. Frequent changes among the decision-makers within 
the Ministry of Health can delay the implementation of any effective 
program. Ophthalmologists may find themselves again and again 
trying to convince new bosses about the virtues of eye-care programs. 

Successes and failures of the Ministry in general do affect the 
eye-care program. The competition of many Ministry activities for 
resources is perhaps the best example of this. Some suggestions for 
an ophthalmologist to overcome such a situation: be patient; try 
to accumulate managerial authority, yet be sure to retain your 
ophthalmic skill (try to achieve a balance between being a soldier/ 
technician and a general/policy maker); make every effort to win 
supporters for your program; do not lose your connections outside 
of the Ministry— warm relations with the ophthalmic community 
and academicians are especially important; and continually train 
successors. 



6 


WHO Technical Cooperation 

for a National Program 

for the Prevention of Blindness 

Dr A.D. Negrel 

The WHO Program for the Prevention of Blindness (WHO/PBL) 
was established in 1978 through the implementation of a number 
of World Health Assembly resolutions: resolution 22.29 in 1969, 
resolution 25.55 in 1972, and resolution 28.54 in 1975. These resolu- 
tions requested that the Director-General promote national programs 
for the prevention of blindness with special emphasis on those 
caused by trachoma, onchocerciasis, xerophthalmia, cataract, glau- 
coma, and trauma; and to encourage the mobilization of necessary 
resources. As in other fields, the role of WHO must be that of pro- 
moter/catalyst; the final responsibility for implementation of ef- 
fective programs rests with national health authorities. 

The essential components of PBL and its possible technical 
cooperation with Member States are based on a multidisciplinary 
approach and include activities such as: methodology assistance 
in the assessment of blindness and its causes; technical advice and 
support for the formulation of national plans; training auxiliary 
personnel in eye care and consultations on the monitoring and 
evaluation of the methodology of health programs; applied research 
within national programs for effective service delivery; assistance 
in the identification of potential resources for national programs; 
and making available updated and comprehensive documentation 
on technical aspects of blindness prevention. 

For the purposes of this paper the WHO technical cooperation 
will be presented at three levels: 1) the country level (when requested); 
2) the regional level (according to the WHO definition of a region); 
and 3) the global level. 


243 


244 Plenary Session V— National Program Development 

THE COUNTRY LEVEL 

As blindness prevention activities are carried out and gradually ex- 
pand to a national scale, overall coordination becomes necessary 
for planning and evaluation. The formulation of a national pro- 
gram for the prevention of blindness demands the assessment of 
overall needs and resources and requires input from the many sec- 
tors that could contribute to blindness prevention. Such a program 
should be based on a primary health-care approach and include 
both the control of specific blinding diseases and the provision of 
essential eye care to all. 

At this level the WHO/PBL collaborates with its member states 
in the following main fields: 

1. Assessing common blinding disorders. PBL has developed 
a simplified methodology for field surveys on blindness 
and its causes. The objectives and principles for this meth- 
odology are: 

• Providing epidemiologically sound data on the prevalence 
of blindness and low vision; 

• Allowing an assessment of the main causes of visual loss 
and their relative importance; 

• Providing pertinent yet selected information on specific 
ocular morbidity, treatment for eye diseases, and current 
needs for action in terms of eye care; 

• Using low-cost examination technique (with most of the 
field work being undertaken by trained auxiliary health 
personnel); 

• Allowing a rapid assessment of the ocular status in defined 
populations. 

2. Planning local intervention schemes and formulating targeted 
national blindness programs geared to identify local needs 
within the framework of primary health care. 

3. Providing technical guidelines and expertise for monitoring 
and evaluating control measures and program activities. 

One important aspect of developing a national blindness 
prevention program is the inclusion of an evaluation com- 
ponent. To achieve this, PBL has developed simple models 
for evaluation that focus mainly on changes in prevalence/in- 
cidence or in the intensity of eye disease. This is a suitable 
short-term approach. 


WHO Technical Cooperation 245 


4. Training personnel, particularly at the primary and first refer- 
ral (district) levels through the provision of simple eye care 
and the promotion of eye health. 

Another cornerstone for the WHO/PBL is the support given to: 

1. Training manpower through fellowships or grants; 

2. Developing training material in eye care and for public in- 
formation on eye health; 

3. Developing refresher courses and continuing-education 
systems for appropriate personnel; 

4. Establishing national workshops; and 

5. Strengthening selected teaching institutions to promote train- 
ing in the public health aspects of ophthalmology and to serve 
as national/regional centers. 

Some WHO Collaborating Centers for the Prevention of 
Blindness train personnel at various levels. Of particular in- 
terest are regular courses in community eye health, particu- 
larly in prevention and epidemiological ophthalmology. 

The following institutions, according to the global preven- 
tion of blindness strategy, try to prepare their students for 
new professional roles and to provide skills for efficient 
project management: the International Centre for Eye Health 
(ICEH), London, United Kingdom; the International Center 
for Epidemiologic and Preventive Ophthalmology (ICEPO), 
Johns Hopkins School of Hygiene and Public Health, 
Baltimore, Maryland, USA; and Institut d’Ophtalmologie 
tropicale de l’Afrique (IOTA), Bamako, Mali. The programs 
presented by these institutions are suitable for ophthal- 
mologists or others interested in blindness prevention ac- 
tivities, including the managerial and research aspects of such 
programs. 

6. Strengthening of appropriate infrastructure for eye care, par- 
ticularly at the district level (including the transfer of rele- 
vant technology). 

7. Supporting operational and health-systems research to 
generate, improve, and apply optimal technology and man- 
agement in the control of blinding disorders 

The WHO/PBL also has a research component that 
mainly provides modest seed money to applied research 


246 Plenary Session V— National Program Development 

projects. [See the Report of a task force on evaluation 
mechanisms for programs for the prevention of blindness, 
Geneva, WHO, 1984, p. 15. (WHO/PBL/84.9) unpublished.] 
The activities in this field focus mainly on: planning and 
coordinating research relating to blindness prevention and 
applicable technology, for example the provision of spectacles 
at low cost, and supporting epidemiological and health- 
systems research in identified priority areas as part of na- 
tional program development. Such activities are usually 
carried out by a research module within PBL or one or more 
of the WHO Collaborating Centers for the Prevention of 
Blindness, 14 of which have now been designated around the 
world. 

8. Offering assistance upon request to national programs for 
the mobilization of external resources required for organiza- 
tion or for specific aspects of prevention. 


THE REGIONAL LEVEL 

At this level, WHO/PBL assists in collecting, updating, and dis- 
seminating information concerning blindness prevention. Support 
is given to training the middle-level and supervisory categories of 
health workers on an inter-country basis in seminars and workshops. 

PBL also provides technical expertise for regional program 
development in fields such as technology application and opera- 
tions research. PBL also reinforces what is done at the country level. 


THE GLOBAL LEVEL 

PBL maintains a data bank on blindness and collects information 
on trends in the pattern of blinding diseases. Strategies for the early 
detection and management of blinding disorders are developed 
through a global consultation process that includes leading experts 
and institutions. The outcome of this work is available as specific 
reports on meetings or as technical documents and publications 
issued by WHO. 

Training aides in eye care and educational material for generating 
public awareness are developed and adapted to regional conditions. 
Regular interregional or global meetings are held, usually at yearly 
intervals, to allow proper coordination of program development. 


WHO Technical Cooperation 247 


Operational research and new aspects of available technology are 
supported through the network of collaborating centers already men- 
tioned above or through other selected institutions. 


AT ALL LEVELS 

Close collaboration is maintained with international non- 
governmental organizations (NGOs) and United Nations agencies 
working in the field of blindness prevention, eye care, and 
rehabilitation. 

One of the strategies of the WHO/PBL is its strong collabora- 
tion with NGOs. Some of these organizations were operational 
before PBL was established and were responsible for its inception. 
The International Agency for the Prevention of Blindness was 
especially instrumental in its founding. 

Another strategy is to have regular consultations between the 
WHO/PBL and the leading NGOs to facilitate coordination of work 
and joint program development. 

In conclusion, the development of national programs for the 
prevention of blindness has been one of the most successful activities 
of the WHO/PBL and has led to its collaboration with a network 
of international NGOs. Over the last 12 years, 66 member states 
have collaborated with the WHO in the preliminary assessment of 
blindness and its causes, the preparation and formulation of na- 
tional plans of action, or in the implementation and evaluation of 
their ongoing programs. Several more countries are due to follow 
in the near future. 

In the frame of its mandate and from its inception, WHO/PBL 
has always tried to discover, in accordance with the interested 
Member States, the most practical solutions to overcome constraints 
encountered. Some of these obstacles are relatively easy to over- 
come when financial resources become available. Unfortunately, 
others remain great challenges, particularly when changes in lifestyle, 
project management, or professional roles are required. 

Indeed in this context the further prospect of world blindness 
prevention will depend largely, but not exclusively, upon the 
availability and sustainability of resources. This is why the political 
and professional commitment to blindness prevention of both de- 
veloped and developing countries needs to be reinforced around the 
world. 



7 


The Role of the Network of 
Non-Governmental Organizations 
in Starting and Developing 
Sustainable National Programs 

Mr Kevin Carey 

Given the diversity of the international non-governmental organiza- 
tions (NGOs) concerned with eye care in developing countries, it 
is a tribute to them that there is an effective network. The success 
of that network has improved the individual and collective perfor- 
mance of the international NGOs particularly during the past 10 
years. International eye care NGOs are voluntary nonprofit organiza- 
tions based in industrialized countries which work with eye-care 
planners and providers in developing countries to improve services 
and provide technical cooperation and/or program finance. Per- 
sonally I find the term NGO divisive; it separates us from govern- 
ments in a way which is symbolically powerful. When you consider 
that the government eye-care budgets of most developing countries 
are less than the total contribution of the network, the term is even 
more inappropriate. 

Whatever their different backgrounds, all of the eye-care NGOs 
are interested in planned and sustained growth, the delivery of eye- 
care services, and that they provide a high level of professional skill. 

There are approximately 20 international NGOs that can be 
classified as part of the network. They may specialize in dealing 
with governments and national NGOs of and for the blind (Sight 
Savers); work with Christian missions (Christoffel-Blindenmission); 
or work with both (Operation Eyesight Universal). They may 
specialize in technical cooperation (Helen Keller International). 
Some are particularly good at primary eye care (International Eye 
Foundation), and others tend to work in linguistic areas (Organisa- 
tion pour la Prevention de la Cecite and ONCE). Some confine their 


249 


250 Plenary Session V— National Program Development 

activities to eye care whereas others also work with incurably blind 
people dealing with such matters as special education and rehabilita- 
tion. The important point is that the NGOs complement each other. 

The central idea of the network is to combine the strengths of 
the different international NGOs in the network when looking at 
a country’s or a region’s eye-care needs. Say, for instance, it would 
be best to combine Helen Keller International’s technical skills in 
planning with the International Eye Foundation’s primary health 
expertise, or Sight Savers’ secondary level expertise and Christoffel- 
Blindenmission’s expertise on the ground in the country concerned. 
The aim of the network is to carry out these activities through na- 
tional prevention of blindness committees under the umbrella of 
the IAPB. The network also provides a means for strategic planning 
between international NGOs at the policy-making and strategic 
planning levels. 

The least formal and most comprehensive manifestation of the 
network is the Partnership Committee which is open to all the eye- 
care international NGOs plus other international NGOs that 
specialize in services in developing countries for incurably blind 
people. The Committee is governed by a broad-based Memoran- 
dum of Understanding. It generally meets twice a year, once special- 
izing in eye care and once in education and rehabilitation. It 
nominates the 10 Group E members of the IAPB Consultative Board 
which in turn become the Consultative Group. 

The Consultative Group lies somewhere in formality between 
the Partnership Committee and the Program Advisory Group (PAG). 
It meets every two years, alternating with the Program Advisory 
Group and, as a body linked to the WHO, its proceedings are 
necessarily formal. 

The Program Advisory Group, which meets every two years, 
brings together representatives from all WHO regions; the profes- 
sional staff of the Prevention of Blindness Program in Geneva; and 
the Consultative Group of international NGOs as observers. This 
provides the opportunity for a detailed program review and the form- 
ulation of recommendations, taking into account perceived needs 
and the capacity of the entire eye-care system to meet them. 

The IAPB General Assembly draws all these strands together 
for a periodic general assessment that combines the whole network 
with key eye-care people from all developing countries. The net- 
work of international NGOs is represented on the IAPB Executive 
Board by 10 international NGOs that are nominated by the Part- 


The Role of the Network of NGOs 25 1 


nership Committee; these in turn become the Consultative Group 
and the observers at the Program Advisory Group; thus the whole 
system is inter-locking. 

In the fields of work with incurably blind people there is not 
an equivalent density of structure. The Partnership Committee 
discusses problems of mutual interest and its natural recourse is 
to the General Assemblies of the International Council for the 
Education of the Visually Handicapped and the World Blind Union. 

Indeed, one of the challenges facing the international NGO net- 
work in the 1990s is to build a consultative structure for education 
and rehabilitation along the lines of the consultative structure in 
place to deal with eye-care matters. 

How can national eye-care planners take advantage of the net- 
work? First, in most countries there is at least one international 
NGO operating and, in countries where there is more than one, one 
will have been designated as the “lead agency” to ensure that ef- 
forts are not duplicated. This means that you can use one interna- 
tional NGO as the root for requests for assistance to all the rest 
of the network. This only works, of course, if both international 
NGOs and planners stick to the rules. The problem here is that there 
is always a shortage of good eye-care programs and international 
NGOs, which rely on good programs to raise funds, are tempted 
to compete rather than collaborate. This situation would be greatly 
improved if the amount of good programming increased so that 
there was a better balance between programming and funding. I 
am often told that certain targets in eye care cannot be achieved 
because of a lack of resources; usually it is a lack of planning and 
follow-through. I have never yet seen a good eye-care project shelved 
for lack of funding. 

In conclusion, let me say a few words about the future of the 
network. First of all, I think it is time to play down the distinction 
between the government and the non-government sectors; in the 
next decade the private sector will grow stronger as the public sec- 
tor grows weaker. Secondly, the concept of networking will gain 
strength as hierarchical models of organization are seen to be less 
productive. Finally, de-regulation of all sorts will inevitably lead 
to increased competition and the social challenge of the decade will 
be to distinguish between those areas where competition is ap- 
propriate and those where the appropriate vehicle for providing a 
service is collaboration. 

As far as I know, there is not a group of diseases better served 


252 Plenary Session V— National Program Development 

in developing countries than blindness: the commitment of govern- 
ments in terms of policy formulation and planning and service 
delivery during the last decade has been truly remarkable; the na- 
tional NGOs of and for the blind have undertaken rapid expansion 
based on greatly increased professionalism; and these efforts are 
complemented by a network of international NGOs that have a good 
track record, a variety of approaches, the ability to raise funds, and 
a willingness to work with each other and with those who can benefit 
from what we know and what we have. For macroeconomic and 
geopolitical reasons outside our control we are entering the age of 
the NGO. I wonder whether we are properly prepared? 


8 


Current Activities of Non-Governmental 
Organizations in Prevention of Blindness 
and Eye-Care Programs 

Dr. A. Hardenberg 

INTRODUCTION 

We have already heard a brief history of the various major non- 
governmental organizations (NGOs) and also a description of the 
structure within which exist the coordination and collaboration of 
the activities of the NGOs. I would now like to turn our attention 
to the present-day activities of the various organizations in different 
parts of the world. The NGOs work together in more than 100 coun- 
tries around the world and in well over 1,200 individual programs 
with a total eye-care budget of approximately $40 million per year. 


LATIN AMERICA 

In Latin America and the Caribbean the NGOs support programs 
in more than 20 countries with particular emphasis on the develop- 
ment of cataract surgical programs in rural areas. It is estimated 
that in South America there are between 1.0 and 1.5 million blind 
people with another 500,000 to 800,000 blind in Central America 
and the Caribbean. Cataract is probably responsible for at least 50 
percent of blindness in Latin America. In most countries of the 
region there are sufficient numbers of ophthalmologists in the large 
cities, but the provision of specialist services in rural areas is very 
limited. Various strategies have therefore been developed to pro- 
vide cataract surgical services to poor people living in rural areas. 
Cataract-Free Zones have been evaluated in Brazil and Peru and 
are now being further developed in other countries of the region. 
In city slum areas satellite eye clinics, staffed on a part-time basis 
by ophthalmologists, have been started in some countries to provide 


253 


254 Plenary Session V— National Program Development 

inexpensive eye-care services with a referral system to hospital 
facilities in the major cities for those patients requiring eye surgery. 

Onchocerciasis remains a problem in a few isolated places in 
certain Latin American countries and the NGOs are now involved 
in providing resources for Ivermectin distribution programs. Vitamin 
A deficiency leading to childhood blindness from xerophthalmia 
remains a problem in certain areas of the region and the develop- 
ment of model programs to increase vitamin A nutriture are being 
developed. For the immediate future the NGO community is in- 
terested in supporting the development of national prevention of 
blindness programs, particularly in the poorer countries of Latin 
America in order to provide eye-care services to poor people in rural 
areas and urban slum situations. 


AFRICA 

In Africa the NGOs work in more than 40 countries with some 
organizations focusing their activities in Francophone countries. 
Vertical programs have been supported for the control of onchocer- 
ciasis through Ivermectin distribution and the prevention of xeroph- 
thalmia through improved vitamin A nutriture. In general, however, 
the emphasis in Africa has been on the development of training 
programs, particularly for ophthalmic assistants and ophthalmic 
nurses to provide comprehensive eye-care services at the district- 
hospital level in the context of a National Prevention of Blindness 
program. The NGOs were instrumental in starting the first train- 
ing programs in East Africa in the 1970s and more recently in sup- 
porting the establishment of training programs in West Africa. 

Many countries in the Africa region have active prevention of 
blindness committees, and various NGOs attend their meetings as 
members and advisors. The organizations have been involved in try- 
ing to integrate voluntary and church medical services into national 
planning and programming for prevention of blindness, catalyzing 
the coordination of public and private-sector eye-care services. 

Besides the lack of trained manpower in Africa, there also ex- 
ists a great need for development of appropriate inexpensive and 
low-maintenance technology to provide materials and medicines 
necessary for eye-care services. With this need in mind, the con- 
cepts of low-cost spectacle production in optical workshops and 


Current Activities of NGOs 255 


local production of eye drops in hospital pharmacies have been 
developed and promoted by the NGOs throughout the African 
Region. 


ASIA 

In Asia we have been particularly involved in the problem of cataract 
blindness, in many countries but most notably India, as well as 
assisting in the development of programs to combat vitamin A defi- 
ciency in children. The development of the prevention of blindness 
program in Nepal over the last 10 years and the organization of 
different NGOs to be responsible for eye-care services in the various 
districts of Nepal with coordination from the national committee 
is an excellent model for how national governments and different 
NGOs can work together to develop a cost-effective prevention of 
blindness program. Several NGOs have now started projects in China 
and in countries of South-East Asia. 


CONCLUSION 

On a more general level, the NGOs have supported various inter- 
regional and regional workshops on childhood blindness, manpower 
development for Africa, and the local production of eye drops. Next 
year a workshop will be supported on the theme of Ivermectin 
distribution. All the NGOs consider training of eye personnel a high 
priority in their programs. WHO will help develop and support the 
production of educational materials and give sponsorship for train- 
ing programs particularly in community eye health. 

In conclusion, there is no doubt that the last decade has brought 
a much greater understanding on the part of NGOs of how to in- 
itiate, develop, and coordinate eye-care programs in different parts 
of the world. Mistakes have been made, often through inadequate 
preliminary assessment of the problem, poor communication be- 
tween various involved parties, and naivety in terms of the long- 
term consequences of what initially seems like a good idea. The 
fact that people mean well and work hard does not necessarily mean 
that the result will be good. Individually and collectively the NGO 
community has learned (and is still in the process of learning) the 
lessons of long-term planning with ministries of health and local 


256 Plenary Session V— National Program Development 

voluntary organizations to develop sustainable eye-care services in 
order to reduce the number of blind men, women, and children in 
the world. 


9 


The Role of Non-Governmental 
Organizations in the Development of 
a Sustainable National Program 

Mr John M. Palmer ; III 

Familiar themes of this plenary session concern international non- 
governmental organizations (NGOs) and how we should work as 
a group to initiate, develop, and support sustainable prevention of 
blindness activities and improve our collaboration during the 1990s. 

David Korten, an acknowledged commentator on international 
development, has categorized agencies such as Sight Savers, 
Christoffel-Blindenmission (CBM), Helen Keller International 
(HKI), the International Eye Foundation (IEF), Organisation pour 
la Prevention de la Cecite (OPC), and Operation Eyesight Univer- 
sal (OEU) into three classifications: 

First-generation organizations, known as relief and welfare agen- 
cies, involve private voluntary organizations (PVOs) that directly 
deliver services to meet immediate human needs. Second-generation 
organizations seek to strengthen self-reliance in selected localities 
through community-development interventions. Third-generation 
PVOs are directed toward achieving sustainable changes in resource 
management systems to improve the generated flow of benefits. 

The agencies represented at this Fourth General Assembly cer- 
tainly represent each of these categories. Most of you know who 
we are and how we work. I think it might be informative for us 
to hear about how you perceive each of our agencies and the model 
it fits. Multiple models might be pertinent in the case of some proj- 
ects. Whether we meet your immediate and long-term needs also 
would be useful information. For example, we think that HKFs mis- 
sion is explicitly aimed at third-generation approaches to the inte- 
gration of eye health, prevention, treatment services, and rehabilita- 
tion of the blind. In addition, we certainly perform first-generation 
activities in meeting immediate human needs, and also support self 


257 


258 Plenary Session V— National Program Development 

reliance through the second-generation strategy of institution 
building, manpower development, and community-based programs. 

Under the third-generation system of influencing eye-care de- 
livery, goals and objectives are reached through the establishment 
of pilot programs, evaluation, expansion, replication, and nation- 
wide policy adoption and integration. Benefits from model programs 
in one region are tested, evaluated, and adapted nationwide. 

Not all NGOs work identically. Looking toward the 1990s, 
however, I think that there are at least four characteristics that should 
shape our approaches to blindness prevention: 

1. Research: As needed, we should conduct baseline studies on 
the prevalence of eye-health problems and then use the re- 
sulting data to demonstrate the need for prevention and treat- 
ment in national policy. We then need to match this with a 
definition and catalogue the capacity of existing health sys- 
tems and the accessibility of existing services. 

2. Training: Training in planning and management of primary 
eye care as part of the primary health-care system is critical 
to a successful program and should be undertaken with local 
counterparts. HKI normally works under Ministry of Health 
auspices. We jointly analyze and plan as part of the process 
of evaluation. Data management, analysis, and performance 
review based on pilot programs should be integrated as regular 
parts of program administration. 

3. Appropriate Technology Transfer: Most of our organizations 
advocate the transfer of appropriate health technology such 
as eye charts, simple eye loupes (instead of operating micro- 
scopes and more costly items), and cryo-extractors (instead 
of costly irrigating and aspirating devices). 

4. Cost-Effectiveness: We must continue to conduct cost anal- 
yses and organization analyses that justify the cost of pro- 
viding eye health in terms of benefit to society. The economic 
contribution of a rehabilitated blind person or the income 
gained through the improved health of individuals is stressed. 
This documentation will assure economic justification for 
national policy makers that eye health should be a priority 
among all their pressing needs. We should not neglect, how- 
ever, the humane importance of preventing blindness irrespec- 
tive of the economic return. 


The Role of NGOs in a Sustainable National Program 259 

Most of us have been engaged in the global effort to prevent 
blindness for decades. Cynics might ask: “If you’re so good at what 
you do, why is blindness increasing at such an alarming rate?” 
Perhaps as we face the nineties, we should learn from the lessons 
of history: 

Careful planning is necessary if we are to have a positive in- 
fluence on national health-care policy. The following factors im- 
pact on program sustainability and the prospects for expansion. 

1. National interest in model eye-care programs must be con- 
sidered. Government interest can be influenced by awareness 
of blindness prevention programs and this awareness can 
change the priority given them. 

2. A government’s capacity to sustain and replicate programs 
is influenced by the availability of human, financial, and 
organizational resources. 

3. Program readiness for replication is influenced positively by 
demonstrated program effectiveness and the transferability 
of systems. Conversely, it is influenced negatively by the use 
of unique resources not readily available. Is the program likely 
to run down after initial enthusiasm disappears? 

4. Initial replication success is imperative to overcome the dif- 
ficulties that can be encountered in the initial expansion of 
a program. 

Finally, we have found that often the success of a program can 
be traced to the timely selection of a host country familiar with 
public health policy, committed to eye care, and courageous enough 
to take on the Ministry of Health priorities. 

And so what of the nineties? One of the great challenges fac- 
ing NGOs in the coming decade is to sustain the substantial growth 
in funding and program outreach we experienced in the 1980s. 

For example, in 1980 HKI supported six country programs with 
a budget hovering around $1 million. In the past 10 years, our pro- 
grams have increased over sixfold to include 38 country programs 
in 1990. Similarly, our budget has multiplied eightfold since 1980. 
As Kevin Carey noted, other NGOs have also experienced major 
expansion. Continuing that rate of growth in the current economic 
environment will be difficult. 

The opportunities we have discussed this week summon us to 
intensify our fund-raising efforts in order to exceed our past per- 


260 Plenary Session V— National Program Development 

formance. However, the global climate at the outset of the nineties 
indicates that it will be something of an accomplishment for us to 
simply sustain the level of support we achieved in the proceeding 
decade. 

Another challenge facing our International Partnership of PVOs 
dedicated to blindness prevention is to do for ourselves what we 
ask of our national counterparts: just as we advocate the need for 
the articulation of national strategies for blindness prevention, so 
we need to give the form and substance of a global strategy for blind- 
ness prevention in which each of our agencies assumes a role. We 
should collectively agree on a global plan for the decade of the 
nineties, identify the appropriate roles for each member agency, and 
then implement a coherent and concerted action to accomplish our 
goals and objectives for the next 10 years. We cannot afford the 
outrages of parochialism, competitiveness, redundancy, or the sheer 
waste of effort caused by poor cooperation, inadequate planning, 
or isolated and unrelated program activities. These impediments 
too often retard our current performance. 

However, there are encouraging signs. Not long ago, at a meeting 
of the Partnership in Kingston, Jamaica, representatives of our agen- 
cies agreed to meet this spring in Geneva under the aegis of the 
WHO to map out a unified inter-agency agenda for the distribu- 
tion of Ivermectin and the eventual eradication of onchocerciasis. 
Each agency in the Partnership will accept a role and the community 
of NGOs will move as one body in an effort to successfully control 
river blindness. Another more modest example will occur in Haiti, 
where members of the Partnership working there have agreed to 
assist the Haitian Blindness Prevention Committee in the develop- 
ment of a national program for blindness prevention. Members of 
the Partnership will then assume responsibility for supporting the 
national program by taking specific roles in a mutual strategy. 

This Partnership of international non-governmental organiza- 
tions is truly an interdependent community. Each of us, by Korten’s 
definition, exhibits a unique operating style and philosophy and 
we are enriched by our diversity. The world will be improved, 
however, not by the brilliance of our differences but by the effec- 
tive integration of our strengths as we work in concert to save sight 
and save lives. 


10 


The Role of an African National NGO 
in the Development of a 
Sustainable National Program 

Mr Michael A. Dunsford 


INTRODUCTION 

The Kenya Society for the Blind was established by an Act of Parlia- 
ment in 1956. Previously, it had been an extension of the British 
Empire Society for the Blind, later the Royal Commonwealth Society 
for the Blind or Sight Savers. When Parliament established the Kenya 
Society for the Blind, it made it clear that the Society was expected 
to fulfill both medical and social roles, or as the legislators put it, 
“to do all things appertaining to blindness.” 

Thirty-four years later, we are delighted as a Society to record 
significant successes in the medical, educational, and rehabilitation 
fields. This paper seeks to highlight the major developments of the 
Kenya Society for the Blind in blindness prevention and the educa- 
tion and rehabilitation of the visually handicapped and to discuss 
the Society’s perceived role in the 1990s and beyond. 


EYE CARE 

From the outset the Kenya Society for the Blind performed the role 
of a bridge between the Ministry of Health and international agen- 
cies. In 1957, just a few months after its establishment, the Society 
persuaded the Ministry of Health to join it and the Royal Com- 
monwealth Society for the Blind to carry out the first blindness 
survey in Kenya. The result of this survey was that from then 
henceforth the Society acted as a link between the Ministry and 
other national and international NGOs participating in the Kenya 
Ophthalmic Program. 


261 


262 Plenary Session V— National Program Development 

The foundations of the Kenya Ophthalmic Program can be 
traced to this 1957 ocular-status survey which indicated that the main 
causes of blindness in Kenya were preventable: cataract, trachoma, 
glaucoma, and a host of minor conditions, including xerophthalmia, 
injuries, and measles. The survey also indicated that the bulk of 
these eye problems were to be found in rural areas. These two con- 
clusions formed the basis of priorities which led to the develop- 
ment of the Kenya Ophthalmic Program. First, it was realized that 
there would not be enough eye surgeons for the country immediately 
and therefore, it was decided that ophthalmic paramedical must be 
trained and deployed in rural areas. The first such ophthalmic 
clinical officer was trained in 1959 and in 1960 was deployed to 
render ophthalmic services using a motorcycle. His training was a 
joint effort of the Ministry of Health, the Royal Commonwealth 
Society for the Blind, and the Kenya Society for the Blind and 
marked a further strengthening of the partnership that had begun 
in 1957 and which has persisted to this day. 

The first mobile eye unit, conducted on a motorcycle was 
launched as we have indicated in 1960 under the following 
arrangement: 

1. The Ministry provided the medical personnel and the base 
for the Mobile Unit; 

2. The Royal Commonwealth Society for the Blind provided 
the motorcycle and funding for its maintenance; 

3. The Kenya Society for the Blind provided management and 
supervision of the eye unit and handled reports to both the 
Ministry of Health and the Royal Commonwealth Society 
for the Blind. Later, this arrangement expanded to include 
not only these three parties, but also other organizations such 
as AMREF, Operation Eyesight Universal (Canada), Prof. 
Weve Foundation (The Netherlands), the International Eye 
Foundation (USA), and Sight by Wings and Lions Clubs. 

As the family grew, so did the need for coordination. This led 
to the formation of the Prevention of Blindness Committee in 1966 
with the Kenya Society for the Blind being given the role of coor- 
dinator and later its secretariat. Side by side with these developments, 
was the steady expansion of mobile units which by 1963 had shifted 


The Role of an African National NGO 263 


from motorcycles to Land Rovers and which were rapidly growing 
in numbers as more organizations provided funding for them. This 
development demanded more ophthalmic clinical officers and hence 
the need for a local training program for them. By 1982, it was clear 
that the Society had to assume heavier management responsibilities 
for the 14 mobile eye units as well as a large number of Ministry 
of Health personnel involved in this program. It therefore became 
necessary to actively seek to strengthen the Prevention of Blind- 
ness Committee; this was achieved in early 1983. 

The Society has maintained its role as a link between the Ministry 
of Health and the NGOs up to the present time and will continue 
to do so in the future. In addition to acting as a bridge, the Society 
also provides active leadership and fund-raising to the Ophthalmic 
Program which in turn gives it the flexibility to expand horizontally 
and vertically. 

Over the next five years, the Society plans to assist the Ministry 
to establish eye departments in provincial and major district hos- 
pitals. This commitment places a heavy fund-raising responsibility 
on us, a challenge we shall take up to ensure that appropriate 
facilities are availed to the citizens of Kenya. Blindness prevention 
and cure represents about 50 percent of our efforts currently. This 
underscores the importance we attach to the need to prevent prevent- 
able blindness and to cure curable blindness because if this can be 
achieved, less resources will be needed for education and rehabilita- 
tion of the blind. 


EDUCATION AND REHABILITATION 

The Society has always been aware that visually handicapped per- 
sons require special equipment and has adapted methods of teaching 
and training. For this reason, the Society is engaged in a vigorous 
education and rehabilitation program in partnership with interna- 
tional NGOs and the ministries concerned. 

It supports educational programs with special equipment and 
other technical support services. Our involvement in this field has 
enabled the Ministry of Education to set up an integrated program 
which enables blind persons to learn in the same classroom with 
their sighted counterparts. 

The Society is currently engaged in training blind persons to 
become self-employed through farming, baking, carpentry, joinery, 


264 Plenary Session V— National Program Development 

tanning and leather work, knitting, and tailoring especially for par- 
tially sighted persons. Those who wish to become farmers but have 
no land of their own get assistance from the Society to acquire land. 
Over the last two years, the Society and its partners have purchased 
small holdings for 11 families. 

A program assists potential blind businessmen to set up their 
own businesses. Not all blind persons can become farmers or 
businessmen, therefore a program has been set up that is aimed at 
establishing income-generating projects that are run on commer- 
cial lines and which in turn provide formal or industrial employ- 
ment to skilled blind persons. The first of these projects, a bakery 
for the blind, has just opened and is yielding encouraging results. 
Eight blind persons and five sighted ones have found salaried 
employment in this project. We are committed to develop more 
income-generating projects in all areas of industry where blind per- 
sons can perform efficiently. 


THE KENYA SOCIETY FOR THE BLIND TODAY 

At present, our 19 mobile eye units examine and treat over 250,000 
patients annually, which represents about half of the total patients 
reached by the entire program. The 20th mobile eye unit is the only 
mobile teaching program which on average annually gives one-day 
seminars in basic eye care to some 2,000 schoolteachers, general 
health workers, and community leaders through whom we hope to 
pass primary eye-care messages to the community level. In addi- 
tion, the Society through assistance from its partners and the 
Ministry of Health currently provides management to the first Na- 
tional Eye Drops Production Unit situated at the Society offices. 
When fully operational, this Unit will produce a dozen or so basic 
eye drops needed by the Kenya Ophthalmic Program. We are cur- 
rently building a new eye department in a provincial hospital and 
planning to expand the teaching facilities for ophthalmic surgeons 
at Kenyatta National Hospital early in 1991. Overall, we hope to 
complete four new eye departments and to renovate or extend 13 
eye clinics in government hospitals by 1995. Our Eye Health Infor- 
mation Unit is in the process of being computerized and should 
within the next year or so be capable not only of receiving eye-care 
data but also of analyzing them for purposes of continuing policy 
formulation and implementing and evaluating the program. In 1989, 


The Role of an African National NGO 265 


the unit received data from 36 out of 46 government eye depart- 
ments and in 1990 the unit expects to receive data from all of the 
46 government eye clinics as well as from church missions and NGO 
programs. 

In the field of education and rehabilitation, the Society is cur- 
rently pursuing a program of assisting all parties concerned to 
develop strategies aimed at integrating blind persons both at school 
and at work. The Society is developing pilot projects to serve as 
examples of what blind people can do. Since 1986, the Society has 
trained over 40 farmers who on the whole, are presently self- 
sufficient in their daily needs. The Society is currently able to train 
only 12 farmers a year, but we hope to expand this significantly 
by 1995. 

The Society has also assisted some 20 small scale businessmen 
through loans and other support. The experience has led to the 
development of a new approach to this program which entails a 
three month formal training in basic business skills of all clients 
prior to commencement of their businesses. This new program will 
be launched in 1991. Our bakery at Embu is the first commercial 
Bakery for the Blind which emphasizes the Society’s desire not only 
to find new jobs for blind Kenyan’s but also to participate in the 
economic development of this country. The bakery has not just 
created jobs for eight blind and five sighted persons, it is also fulfill- 
ing a local need for bread. And, of course, it has exposed us to the 
exciting business of commercial competition. This year, the Socie- 
ty participated in two exhibitions and one show at which items made 
by skilled blind men and women were displayed and sold. From 
the public response, I am convinced that blind persons should be 
given every opportunity to participate in crafts, industry, agriculture 
and commerce. We in the Society are committed to the develop- 
ment of pioneer programs in these fields. 


CONCLUSION 

In concluding my discussion, let me note that the Kenya Society 
for the Blind is the principal national organization for the blind 
in Kenya. Its role in the provision of services to the blind include: 

1. Providing leadership and advocacy; 

2. Coordinating local and international fund raising; 


266 Plenary Session V— National Program Development 

3. Collecting data on programs for the blind and blindness 
prevention; 

4. Registration of blind persons; 

5. Promotion of general welfare for the blind; 

6. Creation of public awareness about blind persons and pro- 
grams designed to prevent or cure blindness or otherwise im- 
prove the lives of blind persons through education, training, 
and rehabilitation; 

7. Advising the government and other organizations or persons 
on all matters affecting the blind. 


11 


The Role of an Asian National NGO 
in the Development of a 
Sustainable National Program 

Mr K.S. Gupta 


THE ORGANIZATION 

Essential Characteristics of a Model Self-Sustaining Program 
for the Prevention of Blindness: Lok Kalyan Samiti 

Lok Kalyan Samiti (LKS) or People’s Welfare Organization is a 
voluntary, nonpolitical, nonprofit health and family welfare organ- 
ization which was started in New Delhi, India, in 1952 with the 
primary objective of providing medical relief for the poor. 


SOLVING THE PROBLEM OF CATARACT 

Poverty and ignorance directly contribute to the increasing number 
of health-related problems in India. Blindness is a major problem 
which of late has gained some attention from Indian authorities 
due to the shocking increase in the numbers afflicted. Cataract, 
glaucoma, nutritional deficiencies, and refractive errors are the ma- 
jor causes of these cases of blindness. Cataract, by far the most 
common cause, is a disorder that clouds the lens of the eye, thereby 
obstructing the passage of light and gradually leading to blindness. 
Through cataract surgery, the cataractous lens is removed and vision 
is restored. LKS performs cataract eye operations by organizing eye 
camps from our hospital base. Since the inception of this program 
in 1976 we have restored eyesight to more than 17,000 people. These 
individuals have been able to return to the mainstream of society 
and are now able to lead useful and dignified lives. 


267 


268 Plenary Session V— National Program Development 

HOW LKS OPERATES 

LKS operates through eye camps, which in India have an extensive 
history of trial and error. In light of this vast experience, we have 
come to the conclusion that the best results of eye surgery can be 
obtained by adopting the following procedures. 

1. Bring the patient to a hospital complex. 

2. Operate in a well-equipped operating theater and use ex- 
perienced eye surgeons. 

3. Keep the patient in the hospital for a few days. 

4. Follow up with a mobile unit at a location near the patient’s 
home. 

We organized our first eye camp in 1976 in a village called Badar- 
pur, situated just outside Delhi. The manual work we needed to 
accomplish in leveling, cleaning, sweeping, and disinfecting the 
ground over which we put up Shamiyanas (tents) was stupendous. 
How hard and demanding it was can well be gauged by the fact 
that even the drinking water had to be transported from Delhi. That 
year we conducted two eye camps in different locations that ac- 
counted for 212 eye operations. The exercise continued in this fashion 
for the next three years with one eye camp each year, operating on 
a total of 225 patients. 

The eighties proved to be a turning point for the meteoric rise 
in the number of patients seen and the number of operations that 
have restored vision. The foundation stone for the LKS eye hospital 
was laid in 1981 and until the end of the decade (in 1989) we organ- 
ized as many as 211 camps operating upon 13,940 patients. In 
addition, we are credited with nearly 100 percent success rate. How 
did this remarkable achievement come to pass? 

Experience has taught us to develop norms and criteria that are 
meticulously adhered to. Nothing is left to chance. For example, 
the moment a patient is selected for surgery, laboratory tests, 
especially for diabetics, and a complete general medical examina- 
tion for hypertension, asthma, etc. are performed and a provisional 
admission card is given to the patient. This procedure also applies 
to patients living in far-flung villages. Our medical mobile unit goes 
there and conducts these tests in the village itself. 


The Role of an Asian National NGO 269 


MOBILE EYE UNITS 

We now have a completely mobile eye unit to look after patients 
in villages and remote places; but if any major problems arise, the 
patient can be transported to the main hospital in New Delhi. Our 
mobile unit, which is fully equipped with all necessary medicines, 
has an eye specialist, a nurse, a social worker, and a driver. 

The functions of the mobile eye unit are as follows: 

1. To conduct outpatient department (OPD) services in villages 
and give treatment to needy patients free of charge. 

2. To select patients for surgery. These individuals are given pro- 
visional admission cards. 

3. To perform a proper follow-up examination of those patients 
who have already been operated upon. 

4. To remove stitches when required. 

5. To bring the patients from collection points in villages to the 
main hospital and return them home after the operation. 

An important link between the mobile unit and the patients is 
the presence of a medical social worker who works as a liaison be- 
tween the villages and LKS. He or she consults with the doctor, 
schedules follow-up visits, organizes OPDs, brings the patients in 
for operation, and returns them to their villages after surgery. The 
social worker is fully responsible for complete programming of the 
mobile unit. 


PROCEDURE FOR EYE SURGERY 

To give maximal possible benefit to the poor we have regular eye 
camps that are organized as follows: admissions are on Wednes- 
day, the operations are on Friday, and the patients are discharged 
the following Tuesday. 

The moment a patient is selected by these camps for an opera- 
tion everything is provided totally free of charge for him or her. 
Pathology tests, medicines, the operation itself, the hospital stay, 
food, eyeglasses, and the follow-up visits for six weeks are all pro- 
vided free of charge. 

Patients who come directly to our OPD are examined, those re- 
quiring an eye operation are registered and each is given a provi- 
sional admission card. This card contains the name of the patient, 


270 Plenary Session V— National Program Development 

his complete address, the type of operation required, and the date 
and time of the surgery. Patients are also treated for other health 
problems including diabetes, hypertension, and asthma. 

Patients from remote places are picked up by our mobile vans 
after being selected earlier for operations by the mobile unit doc- 
tor. These patients also receive a general medical check-up and 
pathology tests from the mobile unit in their home village. These 
patients are also given provisional admission cards. 


DAY OF ADMISSION TO THE HOSPITAL 

Patients come on the prescribed day and time for admission with 
their provisional admission cards. A general eye examination is per- 
formed to confirm findings previously recorded. The type of eye 
operation needed and the sterile condition of the eyes are assessed. 
In a few cases test bandages are applied for 24 hours. Then a general 
examination by a physician is done to assess the present condition. 
The patient is admitted only after he or she is determined fit by 
the physician. 

During the period in which patients are being examined by our 
doctors, their attendants, usually family members, are kept busy 
watching films in the auditorium. This makes our work easier 
because it keeps the attendants from interfering in our work. 


TRANSIT EYE CAMP 

A unique and important feature of our program is the transit eye 
camp. Here we admit patients who have been rejected from a camp 
because of one health-related reason or another, but who are ex- 
pected to recover in time for the next camp. These are mostly poor 
villagers from remote places who, during their treatment period, 
will stay in good hygienic conditions, eat nourishing food, and 
receive the treatment they require, all free of charge. 

Now is the time for patients and their attendants to learn ex- 
actly what their schedule will be until they are discharged and about 
the food and medicines they will be given. All of their questions 
concerning these and other related topics will be answered at this 
time. 


The Role of an Asian National NGO 271 


SURGICAL PROCEDURE 

In our Lok Kalyan Samiti Eye Hospital we have a most modern, 
air-conditioned operating theater. Four operations can be simultan- 
eously conducted in this facility. Normally three surgeons operate 
while the next patient is being prepared, thus saving much time. 

POSTOPERATIVE CARE 

Patients are looked after by a staff that includes doctors, nuns, ward 
ayas (nurses), and boys. Important features of postoperative care 
include: 

1. Presence of a resident eye surgeon 24 hours a day. 

2. A physician on call 24 hours a day. 

3. Ambulance service available 24 hours a day in case an 
emergency should arise. 

4. Daily eye dressing during the patient’s hospital stay. 

5. Visitors are allowed to see the patients only between 4:00 and 
6:00 p.m. 

6. A medically advised menu of high nutritional value is given 
to the patients during their stay in the hospital. 

DATE OF DISCHARGE FROM THE HOSPITAL 

The final eye dressing is done and patients are told to remove their 
dressings after they have been at home for 48 hours. 

Items issued at discharge to ensure good postoperative care: 

1. Medicines including eye drops, ointments, and tablets to be 
used for a period of seven to ten days. 

2. An instruction leaflet with “do’s and don’ts” printed in 
English, Hindi, and Urdu. 

3. A prepaid envelope with our hospital’s address, so that the 
patient can inform us of any problem. (After receiving notice 
of such a problem, our mobile team is able to reach the pa- 
tient within 24 hours.) 

4. A food packet. 

5. Finally, patients are advised to report to the hospital in case 
of any emergency. We will pay the travel costs spent by the 
patients. 


272 Plenary Session V— National Program Development 

Patients who have been accompanied by relatives are able to 
travel home with these attendants. Patients from villages (about 
55-60 percent of the total) are generally transported home by our 
mobile vans. 


FOLLOW-UP 

A proper and timely follow-up is as important as the surgical pro- 
cedure itself. We conduct a follow-up program for patients from 
outlying villages so that every one of them will be examined be- 
tween seven and ten days after being released. If a patient requires 
re-admission during this period, he or she will be brought back to 
the hospital by van and will be re-admitted. Such patients will re- 
main in the hospital until their problems have been rectified. 


LKS SERVICES ARE PROVIDED FREE OF CHARGE 

None of our services will be charged to the patient during a period 
extending to 40 days from the date of surgery. Eyeglasses will also 
be provided free of charge after a proper test is conducted in the 
mobile van. 


CONCLUSION 

The procedures outlined above constitute the typical cycle for restor- 
ing eyesight that transpires at the Lok Kalyan Samiti Eye Hospital 
in New Delhi. By following these procedures with a spirit to help 
and serve the people, we have progressively grown and achieved bet- 
ter and better results. Many voluntary agencies have visited us over 
the years to see the workings of LKS and to gain practical knowledge 
about our system and methodology. This has given us great satisfac- 
tion and has been a source of moral support to the LKS organiza- 
tion as a whole, allowing us to work with renewed enthusiasm. 


12 


The Role of an International NGO 
in the Development of a 
Sustainable National Program 

Dr. A.T. Jenkyns 

It is a privilege to be sharing this section of the Plenary Session 
with the Chairman of the Kenya Society for the Blind. It was 20 
years ago that a national NGO (the Kenya Society for the Blind) 
and an international NGO (the Royal Commonwealth Society for 
the Blind) joined hands with still another international NGO (Op- 
eration Eyesight Universal). Together this partnership continues to 
carry out a national program of rural eye care with a fleet of mobile 
eye units. 

What I am going to say today applies to large-scale national 
programs and to small-scale NGOs. What are some strategic com- 
ponents as to how sustainable national programs might begin? First, 
I will discuss the knowledge and political will necessary to meet 
the needs of a particular geographical area. 

A Mission Statement or clearly defined statement of objectives 
helps an organization concentrate on what the group is trying to 
accomplish. Starting small and efficiently leads to successful growth 
on a sound foundation. Being big is not always being better! 

How can a program develop? Here are some thoughts: The key 
is to have a business plan. This begins with setting targets and outlin- 
ing on paper what you want to do. This list of targets may be long, 
so list them in priority order according to their importance. The 
list may be beyond your present funding ability or manpower 
resources. If so, lay out your plan over five years with a 10-year 
horizon for targets. 

Revise your plan each year so you are always looking into the 
future decade. The business plan should incorporate all components 
of your organization: program activities, fund-raising, administra- 
tion, and personnel. 


273 


274 Plenary Session V— National Program Development 

How do you work toward the goal of becoming self-sustaining? 
Unless it is your ultimate goal, you will never become self suffi- 
cient. Here are some suggestions about how to become self- 
sustaining. Work on a balanced budget. If you cannot raise the 
money— do not spend it! 

Plan for and work toward increasing your own fund-raising 
capabilities in your own country. This reduces your dependency on 
foreign funding and makes you independent. We have as a partner 
a national NGO in Delhi, India, which is increasing its own fund- 
raising dramatically. In 1990, our support was $102,000, but in 1991 
it will be $78,000. The NGO is carrying out a plan leading to its 
complete self-sustainability. This project partner is Lok Kalyan 
Samiti and its Honorary Secretary is Mr. Kalyan Gupta. 

Build self-sustainability on your own manpower as well as fund- 
ing. Over the years, the success of your program will depend on 
your ability to develop your own people to serve your own people! 


13 


Corporate Interaction Relating to Future 
Prevention of Blindness Programs 

Dr. J. Gmunder 

TASK FORCE “SIGHT AND LIFE” 

In view of its many years of experience in the field of vitamin A, 
F. Hoffmann-La Roche Ltd. felt duty-bound to offer its assistance 
in finding practical solutions to existing problems. To lend shape 
and greater force to previous activities, Task Force “Sight and Life” 
was founded in early 1986 to provide selective aid to combat severe 
vitamin A deficiency. 

Roche believed that its knowledge and contacts over many years 
with leading international and private organizations would enable 
it to make an effective contribution to eliminating this urgent, 
worldwide health problem. Moreover, the Task Force aims to help 
research the complex interrelationships between nutrition and 
childhood mortality and morbidity. 

From the beginning it was obvious that the Task Force should 
keep waste to a minimum and provide funds to promote suitable 
existing projects rather than create identical parallel programs. The 
activities of the Task Force are based on humanitarian grounds and 
are committed to work in the following fields: 

1. Scientific and technical support for the development and im- 
plementation of vitamin A programs; 

2. Donations of free vitamin A for active programs and in 
emergency situations; and 

3. Financial contributions to research, education, and training 
projects. 

The following priorities have been established: 

1. The Task Force is active only in countries where a serious 
problem of xerophthalmia has been identified according to 
WHO criteria; 


275 


276 Plenary Session V— National Program Development 

2. The projects selected for support must be backed by local 
health authorities; and 

3. The infrastructure necessary for careful and proper im- 
plementation of the project must be available. 

The Sight and Life program also has an information component. 
One objective of the Task Force is to raise the awareness of popula- 
tions in industrialized countries about the problem of vitamin A 
malnutrition and xerophthalmia in the developing world and to en- 
courage other organizations and enterprises to support concrete 
measures to combat blindness. 

Creating awareness of a serious health and nutrition problem 
in the developing world may help to establish a sense of concern 
for the underprivileged and a climate of humanitarian solidarity 
so desperately needed in our world of disparity and distress. After 
4.5 years of activity we feel that the aims and methods of our work 
have proved to be fruitful, particularly with the mixture of direct 
aid, financial backing, and technical support. During that period 
Sight and Life has supported 111 projects in 40 countries: 20 coun- 
tries in Africa, 12 in Asia, and 8 in Latin America. We estimate 
that at least 2 million children have been reached. 

Sight and Life provides one example of how private industry 
can contribute to help solve an urgent and compelling health prob- 
lem in developing countries. 


HEALTH EDUCATION -A FUNDAMENTAL ISSUE 

Distribution of vitamin A capsules cannot be the ultimate goal of 
blindness prevention. Its aim should be enacted through nutrition 
and health -education programs to stress the principle of self-reliance. 

Communication, training, and education are essential com- 
ponents in achieving that goal. Nutrition and health education in- 
volves the process of enabling people to increase control over the 
health of their families. This education is as fundamental as reading 
or arithmetic. 

The factors that determine the health -related behavior of people 
lies beyond the individual level and includes community participa- 
tion and social habits. Health promotion, therefore, requires social 
mobilization, community action, and strong political will to give 
clear priorities to health care for all. 


Corporate Interaction 277 


To create a supportive environment, health promotion has to 
take a broad approach and concern itself with promoting changes 
and new health principles at various levels simultaneously. 

Of paramount importance therefore is the existence of a local, 
skilled, and creative work force with commitment and quality leader- 
ship at all levels of responsibility. 

The potential rewards obtained in return for introducing and 
adopting new nutrition-oriented practices are indeed attractive: 

1. The prevention and control of nutritional blindness among 
preschool-age children; 

2. A drastic decrease of child mortality and morbidity rates; and 

3. A better quality of life. 

It seems that these benefits would encourage everyone to strive 
to attain the necessary changes to have these life-saving innovations 
immediately introduced and observed. 

Quite often, however, elements of deep-rooted social or emo- 
tional resistance growing from traditions may seriously hamper the 
quick adoption of even simple changes in lifestyle or eating habits. 

Despite these well-known problems, we have good reasons to 
remain optimistic. Several case studies in the field of nutritional 
diseases have clearly demonstrated that health education programs, 
properly planned and implemented, may have a substantial and per- 
manent impact on the health status of affected communities and 
population groups. 

Industry can be an important partner and integrator in social 
development and effectively help target audiences. 

Increasingly, the private sector is seeing health education as a 
worthwhile challenge, and is attempting to positively confront the 
problem, be it at the marketplace, at the workplace, or in the home. 
The private sector believes that through “participation in selected 
programs and projects of great social impact, the goal of encourag- 
ing self-reliance in developing countries will be met” (Industry Coun- 
cil for Development, 1990). 

Let me close my remarks with a word from Dr. Hiroshi Naka- 
jima, Director General of the World Health Organization, who said: 

“We must recognize that most of the world’s major health 
problems and premature deaths are preventable through 
changes in human behavior and at low cost. We have the 


278 Plenary Session V— National Program Development 

know-how and technology but they have to be transformed 
into effective action at the community level. 

“Parents and families, properly supported, could save 
two thirds of the 14 million children who die every year— if 
only they were properly informed.” 


14 


Challenges and Priorities 
for the Delivery of Eye Care 

Dr G. Venkataswamy 

INTRODUCTION 

Eye-care services were very rudimentary in India before indepen- 
dence was granted by Great Britain in the 1940s. There were few 
eye hospitals in major towns and cities and training for eye surgeons 
was available only at Madras Ophthalmic Hospital. The first in- 
ternational effort, which was to control trachoma, was started by 
the World Health Organization in Delhi in 1956. A national survey 
was conducted to estimate rural blindness in India. Trachoma was 
endemic in several northern states of India and trachoma control 
was started by the application of tetracycline eye ointment in all 
schools and rural areas. Now trachoma is no longer a public health 
problem in most parts of India. 

In 1971 the Government of India started the distribution of 
massive doses of vitamin A to prevent nutritional blindness in In- 
dia’s southern and eastern states. However, because only a small 
percentage of the children received vitamin A, this program did not 
make an impact on nutritional blindness. A current distribution 
program is attempting to give vitamin A to a larger percentage of 
children and the mass media is being used to educate the public 
on vitamin A deficiency. Nevertheless, blindness in children caused 
by vitamin A deficiency remains a public health problem. 

Eye camps, which were started by a few pioneers to restore sight 
to cataract patients, have received good public support. Some volun- 
tary hospitals have conducted eye camps and state governments have 
started supporting them. In 1961 the state government of Tamil Nadu 
sanctioned two mobile ophthalmic units, one at Madras and another 
at Madurai. I was asked to be in charge of the mobile ophthalmic 
unit at Madurai and four eye operation camps were to be conducted 
each year. A sum of $50 was sanctioned for each camp. We had 


279 


280 Plenary Session V— National Program Development 

to solicit public support to feed the patients and medicines and free 
aphakic spectacles had to be provided to all the operated cases. We 
had numerous bilateral mature and hypermature cataracts and only 
these types of cataracts were admitted for operation. Clean rooms 
with good cement floors were selected and improvised as operating 
rooms after scrubbing and formal sterilization. Four to eight oper- 
ating tables were provided with instrument trolleys. Electric sterilizers 
with boiling water were used to sterilize the blunt instruments and 
sharp instruments were sterilized with chemicals. Three or four sur- 
geons operated at a time and over 150 to 200 cataracts were operated 
each day. The eye camps became very popular with the public and 
cataract patients came by the hundreds. We increased the operating 
teams and in some camps more than 1,000 cataracts were operated 
in a day. 


LARGE-VOLUME CATARACT SURGERY 

In the developing countries of the world there are at least 27 million 
blind people, the major cause of which is cataract. However, cataract 
patients do not need much postoperative care. In fact, in many coun- 
tries they are treated as out-patients. With rural people coming from 
interior villages with poor communications we at the Aravind Eye 
Hospital keep them for four or five days. In addition, cataract pa- 
tients can help themselves by going to the toilet or cafeteria and 
they do not need intensive care. They need only basic residence 
amenities: mats on the floor in a building can accommodate them. 
A team consisting of a well-trained eye surgeon and an ophthalmic 
nurse can operate 15 to 20 cataracts in three to four hours a day. 
If an intraocular lens is implanted as part of these surgical pro- 
cedures, they may take an additional hour. Depending on the need, 
we can have five to ten surgeons operate in a day. All that is needed 
is to have more operating rooms with additional equipment. In 
Aravind’s eye hospitals on just two days a week more than 100 
cataract operations are routinely performed. 


OPTIMAL MANPOWER UTILIZATION 

It is necessary to train the surgical team to improve its skills through 
the use of intense coaching, similar to the training regimens used 
in many sports. Once their skills are perfected, they can be trained 


Challenges and Priorities for the Delivery of Eye Care 281 

to increase the number of operations they can perform in a day. 
Just as tennis players are coached to develop stamina so that they 
can play a match for two or three hours, in Aravind surgeons have 
been trained to operate 50 cataracts or more in a single day. Of 
course, proper facilities are required and you must have a large 
number of patients for such training. An average well-trained sur- 
geon in Aravind performs 2,500 or more cataracts in a year. In Asian 
countries there is a need to do large number of cataracts. A recent 
survey in India estimates that 4 million new cases of cataracts occur 
each year. However, currently only 1.2 million cataracts are done 
each year. This has led to the current enormous backlog of over 
17.5 million unoperated cataracts. We need to operate at least 5 or 
6 million a year. It is possible to operate 30,000 to 40,000 cataracts 
in one hospital if we institute factory-like efficiency. If we had 100 
such hospitals, we could operate nearly 4 million cataracts a year 
and, of course, reduce the backlog considerably. Although such a 
plan will require 3,000 to 4,000 eye surgeons, we have in India more 
than 6,000 eye surgeons at the present time. And we can train more 
eye surgeons each year. Therefore, optimal utilization of manpower 
will help to clear the backlog of cataracts in India. 


REACHING RURAL POOR PEOPLE 

Nearly 70 percent of the population of the country lives in villages, 
mostly working in agriculture and related occupations. They are 
poor and have a high rate of illiteracy. Unfortunately, they are not 
aware of the common causes of blindness and most of them have 
not been to a doctor in their life. The vast majority of eye surgeons 
are available only in large towns. Poor villagers feel too intimidated 
to travel to a town to see a doctor. In addition, a villager might 
lose his or her job and therefore have no money for travel to a town 
or to buy food for the journey. 

We therefore have to identify local voluntary organizations such 
as Lions Clubs, Rotary Clubs, and religious or other groups to re- 
quest them to organize screening eye camps. Their first task is to 
find a suitable place to collect a large number of people with eye 
problems and get a sufficient number of volunteers to help. They 
have to advertise their camp by posters, handbills, loudspeakers, 
and radio and other media. Some of the volunteers will be asked 
to help transport the cases selected for operation and feed them 


282 Plenary Session V— National Program Development 

while they are inpatients in the hospital. Unfortunately, because not 
all voluntary groups may be able to help, we have to find alternate 
sources of support. Most patients need free operations, free hos- 
pitalization, and free medicines. 

Community awareness and participation are essential to restore 
sight to a high percentage of these rural people. Although some 
NGOs will support such an eye camp, a great deal of research is 
needed to perform the level of social marketing necessary to reach 
all of the eye patients who require eye surgery. In addition, it must 
be cost-effective. 


SELF-SUPPORTING SERVICES 

In developing countries there are several constraints to the delivery 
of eye care to all people in need. The state does not have adequate 
resources to do this, and most people do not have medical insurance. 
At the Aravind eye hospitals a model has been developed to make 
the institution self-supporting. First, quality care is made available 
to the community at a modest cost, attracting a large number of 
paying patients. The staff, including the doctors, work full-time at 
a fixed salary. The money generated from the paying patients is used 
for capital expenses like construction of buildings and on equip- 
ment and salaries. In addition, 800 or more screening eye camps 
are organized each year. A separate field staff is available to con- 
tact the voluntary organizations to set up 20 eye camps each week. 
We have 10 vehicles to take our staff to these eye camps. This entire 
operation has to be made self-supporting by efficient use of man- 
power, operating rooms, and equipment. We have to adopt industrial 
efficiency in all our operations. 


THE CHALLENGE 

If we can replicate the Aravind hospital model in hundreds of places 
in developing countries, we can build sustainable institutions to 
remedy the blindness problem in the world. However, this will re- 
quire a strong group of talented people to train the manpower, con- 
trol the finances, and maintain high quality. In the world today we 
find large multinational corporations producing needless products 
like cigarettes, yet they are making a lot of money. And often they 
are employing the best talent and using powerful marketing strategies 


Challenges and Priorities for the Delivery of Eye Care 283 


to hook people to use their products. Other powerful groups use 
their talents for selling drugs. If we could only use the available 
talent in the world today, it should be possible to eradicate hunger 
and many other diseases. We need people to manage large sums 
of money efficiently. And we must be able to train people efficiently 
and make the best use of them. Then we could adopt our base 
hospital technique and operate 30,000 or more cataracts per year 
at each hospital. The quality will be better and we will make op- 
timal use of manpower and achieve cost-efficiency. 



15 


Appropriate Technology for Eye Care 

Dr. G. Venkataswamy 

INTRODUCTION 

Nearly two thirds of the world’s population lives in developing coun- 
tries of the world where the gross national product per capita is 
less than $1,000. The prevalence of blindness in most of these 
countries is more than 1.0 percent. There is also a scarcity of 
trained local eye doctors and ophthalmic technicians in these 
countries. Consequently there is considerable economic loss due to 
the backlog of cataract blindness in these countries and there is 
an urgent need to develop sustainable national programs with ap- 
propriate technology. 


LOW-COST BUILDINGS 

One of the most important aspects of a self-sustaining prevention 
of blindness program is to build low cost buildings that suit the 
weather and the way of living of the local people. At Aravind there 
is an out-patient area and inpatient wards to accommodate 70 pa- 
tients plus an operating room, sterilization room, scrub room, and 
a store room. We also have sufficient bathrooms and toilets for the 
staff and the patients. The entire building cost $12,000, yet the pa- 
tients feel at home and comfortable and operationally this hospital 
is very efficient. 


OPERATING ROOM 

The operating tables, instrument trolleys, stools, and sterilizers all 
were made locally and cost very little. The operating instruments 
were made in India or Pakistan and they are inexpensive, yet very 
good. They could probably be manufactured in most of the develop- 
ing countries. Operating lamps with a sharp-focused light are made 


285 


286 Plenary Session V— National Program Development 

in India and are priced cheaply. Electric generators are also available 
at a reasonable cost. 


DRESSINGS 

Swab sticks, eye pads, wipers, bandages, and irrigating solutions 
and eye drops are made by our nurses. In addition, all the linen 
for our staff and sheets for the patients are made locally. 


SPECTACLES AND TRIAL SETS 

These are also made in-country and are very inexpensive. However, 
we are now importing ophthalmoscopes. Locally made slit lamps, 
operating microscopes, keratometers, and indirect ophthalmoscopes 
are made and their quality is improving. Needles and sutures are 
also manufactured locally and they too are inexpensive. All this il- 
lustrates that we can have appropriate technology for adequate 
delivery of eye care in developing countries. 


MANPOWER DEVELOPMENT- AUXILIARY WORKERS 

Different countries have developed different types of ophthalmic 
workers to suit their needs. In some African countries trained med- 
ical assistants do cataract surgery. In India and other Asian countries 
each institution has trained its own technicians to assist the eye 
surgeons in the operating room, to give local anesthesia, and to help 
in the wards and outpatient areas. At the Aravind eye hospitals we 
train ophthalmic assistants to work in the operating room as well 
as in outpatient and inpatient areas. In addition, they are trained 
to do refraction, tonometry, and test for visual fields. They also 
do major work in screening eye camps. However, we do not have 
many trained nurses; most of them go to countries in the Middle 
East or to the United States. 


COMMUNITY PARTICIPATION 

We build strong contacts with the community and they help to 
organize eye camps — both screening and operating camps. This helps 
to educate the community regarding eye diseases and blindness. 


Appropriate Technology for Eye Care 287 

School and college students learn about common causes of blind- 
ness such as cataract and vitamin A deficiency and motivate the 
people to attend the camps or hospitals. Lions Clubs give high prior- 
ity to sight restoration operations and they help in several ways, 
including setting up eye banks, eye hospitals, and blind rehabilita- 
tion centers. Religious organizations and youth clubs also help in 
eye camps. 

The practical difficulties in organizing operating eye camps are: 

1. Want of school buildings or community halls. It is not easy 
to get adequately large halls for conducting eye camps ex- 
cept during school holidays. 

2. The cost of running operation camps is high and it is not 
easy to get voluntary support. 

3. We must keep the ophthalmologist at the camp site for the 
entire postoperative period (although this prevents optimal 
use of eye surgeons). 

4. We need many volunteers to assist the patients, to take them 
to the toilets, and to feed them. However, it is not easy to 
find volunteers. 

5. Food is more costly in the camps than in base hospitals. 

Therefore, in India there is a shift to increase the work to the 
base hospitals. In the north of India cataract operations are not 
performed during the summer months in either the hospitals or in 
the eye camps. However, this results in poor utilization of the 
hospitals’ beds that have been set aside for eye patients. Now ef- 
forts are made to operate cataracts during the summer months in 
these hospitals. This will help to restore sight to more cataract 
patients in India. 






16 


Monitoring and Evaluation 
of National Programs 

Dr R. Pararajasegaram 

Monitoring and evaluation are integral components of the man- 
agerial process for programs of national health development and 
should be included in a national program aimed at preventing and 
controlling blindness. 

Monitoring 1 is the term used for the continuous follow-up of 
activities to ensure that they are proceeding according to plan. It 
keeps track of achievement, staff movements and utilization, sup- 
plies and equipment, and the money spent in relation to the resources 
available, so that if anything goes wrong, immediate corrective ac- 
tion can be taken. The principles and practice of monitoring for 
the prevention of blindness (PBL) program would follow those of 
any other national program. 

Evaluation 2 is the systematic assessment of the relevance, ade- 
quacy, process, efficiency, effectiveness, and impact of the program. 
Both monitoring and evaluation require the establishment from the 
outset of an appropriate information system at all levels, based on 
regular recording and reporting. Monitoring provides some of the 
information that is required for evaluation. 

Both monitoring and evaluation have to be included at the plan- 
ning stage and resources allocated in the budget for these purposes. 
For monitoring purposes, a time-bound plan of work is necessary. 
For evaluation, clear quantifiable objectives and targets should be 
set and suitable indicators chosen. Indicators would help measure 
changes in the eye-health situation either directly or indirectly. 

Indicators may take various forms depending on what is to be 
evaluated, for example: 

1. Output— The number of personnel trained by the program 

for cataract surgery. 


289 


290 Plenary Session V— National Program Development 

2. Outcome— The number of cataract operations performed by 
the trained personnel. 

3. Impact— The effect on the socioeconomic status of the 
beneficiaries and the community. 

Whereas output and outcome are easier to measure, impact 
measurements require more exacting studies and are less tangible. 
In addition to these measures, evaluation may also assess relevance 
of the program and its adequacy. Specific indicators would need 
to be identified in respect of each of these. 

The reader is referred to more detailed descriptions of these in 
other documents. 3,4,5 

Cost-benefit and cost-effectiveness are additional considerations. 
In the context of resource constraints generally associated with most 
health programs (and the prevention of blindness program is no 
exception) the need for cost containment and optimal utilization 
of resources is a major imperative. To contain costs without losing 
acceptable quality of care, evaluation should also include such issues 
as cost-benefit, cost-effectiveness, and cost-efficiency. Both cost- 
effectiveness and cost-efficiency assessments would help program 
managers make better decisions regarding alternative ways of achiev- 
ing an objective and of optimizing services and resources respectively. 

The following issues are important in terms of evaluation: 

1. Who performs the evaluation? 

Evaluation is generally done as part of the program activity. 
It could be an internal evaluation by the personnel in the pro- 
gram or an outsider (called an external evaluation). National 
programs for the prevention of blindness, depending on their 
size and the degree of their integration with the general health- 
care system, would be evaluated as part of the latter or as 
an independent evaluation. Such is often the case where there 
is an input of external or extra-budgetary funds. 

2. When is the evaluation done? 

Depending on the cycle of the health program, evaluation 
may be carried out on an annual or biennial basis, or as a 
terminal activity in the case of a project with a limited time 
frame. Often a midterm evaluation is less exhaustive than a 
terminal evaluation. 


Monitoring and Evaluation of National Programs 291 

3. What data are required for evaluation? 

Reference has already been made to a built-in information 
system. However, it may be necessary to have recourse to rapid 
assessment survey techniques to determine the effect that the 
program has had on the eye-health status in the served com- 
munity. Such surveys would be required particularly in respect 
of medium-term (0. 5-5.0 years) and long-term targets (over 
6 years). Some data that need to be obtained through ap- 
propriate surveys are: 6 

• Short-term and medium-term (0.5-5. 0 years) 

• Village-level randomized prevalence surveys: 

— of preschool-age children for active xerophthalmia (night 
blindness, Bitot’s spots) and trachoma; 

— of adults over 50 years for blinding cataract and for 
trichiasis; and 

— of a small, representative group for relevant “knowledge, 
attitudes, and practices” concerning eye care 

• Long-term (more than 6 years) 

A definitive prevalence survey for blindness from corneal disease 
(by cause), cataract, and other disorders (glaucoma and posterior 
segment disease). 


USES OF EVALUATION FINDINGS 

The findings of an evaluation are particularly useful both in re- 
formulating and refining the program/project evaluated, and also 
to serve as an object lesson in planning similar projects to be repli- 
cated or initiated within or outside the country. Results of monitor- 
ing usually have more relevance to the particular project and help 
to streamline project activities, resource constraints, and bottlenecks; 
and they generally facilitate more efficient performance. 


SUMMARY 

Monitoring and evaluation are integral parts of any program for 
the prevention of blindness and should be budgeted for at the outset. 
Similarly at the outset, quantifiable objectives and targets should 
be set against realistic time frames and indicators must be identified 


292 Plenary Session V— National Program Development 

for future evaluation. Targets formulated in terms of clear outcomes 
would help to evaluate the impact of program activities and to en- 
sure the relevance of such follow-up analysis to subsequent planning. 

Both activities would save time, effort, and resources in the long 
term. A suitable reporting system needs to be incorporated into the 
program to facilitate both monitoring and evaluation. 

The results of monitoring and evaluation would look not only 
at outputs and outcomes but also at the planning process, relevance, 
adequacy and, in the final analysis, impact in terms of eye-health 
status. 


REFERENCES 

1. Glossary of terms used in the “Health for All” series, No. 1-8. 
WHO, Geneva 1984. 

2. Ibid. 

3. Health program evaluation: Guiding principles (1981). “Health 
for All” series, No. 6. 

4. Report of the task force on evaluation mechanisms for pro- 
grammes for the prevention of blindness. WHO/PBL/84.9. 

5. Eye Health in South-East Asia, No. 5. WHO SEARO, 1985. 

6. Report of the task force on evaluation mechanisms for pro- 
grammes for the prevention of blindness. WHO/PBL/84.9. 


PART/ 


PLENARY SESSION VI 

IAPB 

Business 

Meeting 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 































































1 


Outgoing President’s Address 

Dr. Carl Kupfer 

This has been the most exciting eight years of my professional life. 
It has allowed me to continue to meet those individuals throughout 
the world who are committed to prevention of blindness and who 
provide the leadership and inspiration in this effort, but it has also 
allowed me to see the strengthening of the World Health Organiza- 
tion’s Prevention of Blindness Program as well as the quantum leap 
forward of the non-government organizations in bringing signifi- 
cant resources to these programs and in developing a renewed col- 
legial approach to their activities. In addition, a special note is in 
order to recognize the entry of the Lions’ SightFirst Program into 
the arena of prevention of blindness activities. 

It is traditional for the Outgoing President to review the ac- 
complishments of his term of office. Although one could list an 
impressive array of meetings attended, seminars organized, and 
resolutions passed, I would like to call attention to three ac- 
complishments which have, in my opinion, benefitted the preven- 
tion of blindness programs to the greatest extent. 

During the past eight years, there have been 11 issues of the I APB 
News , which now is mailed free of charge to over 4,500 people in 
148 countries. This worldwide distribution has increased substan- 
tially the communication amongst the international NGOs, the 
WHO Regional Offices, the national committees and the many hun- 
dreds of professionals within ministries of health, hospitals, private 
and public hospitals, and organizations of and for the blind. 

The second accomplishment that merits special attention is the 
formation of the NGO Coordinating Committee. Although the 
NGO organizations attended the Program Advisory Group meetings 
as observers, there was little opportunity to interact directly with 
the WHO Prevention of Blindness Program Manager during the 
press of business. The NGO Coordinating Committee was created 
consisting of the 10 NGOs within the I APB to meet biannually with 
the Program Manager of the WHO/PBL program and his staff and 


295 


296 Plenary Session VI— I APB Business Meeting 

discuss in depth the coordination and cooperation amongst the 
NGOs and between the NGOs and the WHO that is so essential 
for the global program to succeed. I believe that this liaison has 
strengthened the effectiveness of all the organizations involved. 

Thirdly, the broad representation by national delegates at this 
General Assembly reflects the efforts to encourage and assist na- 
tional committees to become more active in IAPB affairs. There 
are 60 national delegations and over 400 registered participants here 
in Nairobi. The most recent National Committee for the Preven- 
tion of Blindness to join the IAPB has been from China. I only 
regret that the recent death of Professor Chan Chow Lu has not 
allowed this leader of Chinese ophthalmology to be present to 
witness the fruits of his efforts. 

In closing my term of office, I would like to reflect on this Fourth 
General Assembly and what appeared to me to be a new theme 
emerging stronger than ever. The concepts of leadership and man- 
agement have been introduced. Leadership refers to making the right 
choice such as choosing the right programmatic direction and the 
right priority judgments. After the right choice has been made, then 
management must see to it that the right choice is implemented 
efficiently. Whereas leadership involves aligning people toward a 
common vision and stimulating their interests, management is con- 
cerned with the details of project staffing, mobilizing needed 
resources, and attending to the many details necessary to do the 
job well. 

In an eye-care delivery program, it is logical and appropriate 
for the ophthalmologist to provide leadership. However, there might 
be another individual better equipped through training and ex- 
perience to carry out the day-to-day details of plan implementa- 
tion and this individual is the manager. Once a programmatic direc- 
tion is identified and a plan developed, the manager is responsible 
for implementation. We must incorporate this concept into creating 
self-sustaining eye-care delivery programs. 

In summary, let us remind ourselves of the need to keep three 
thoughts in mind. First, to set priorities on allocation of scarce 
resources. It is better to do a few projects well in utilizing resources 
effectively and efficiently than to spread the same resources over 
many projects in a limited and inadequate manner. 

Secondly, we must continually be concerned with the quality 
of the outcome of the project; this outcome should represent ex- 
cellence in achieving stated objectives, whether it be in fully restoring 


Outgoing President's Address 297 


vision to the cataract blind or preventing blinding malnutrition. 
Evaluation will tell us whether we have delivered a quality service 
with constituent satisfaction. We should not settle for less. 

Finally, and most important, we must at all times maintain a 
customer-oriented service mentality. In a sense, the blind are like 
hostages. They are held hostage to their disability and are held 
hostage to those of us who can make them see again. They have 
few, if any, options in their quest for a better life. 

Accordingly, we must be especially conscious of the humani- 
tarian aspect of our actions. This feeling for humanity must per- 
vade our thinking, our planning, and our actions. 


































2 


Incoming President’s Address 

Mr Alan W. Johns 

I am conscious of the fact that of all the tasks IAPB Presidents 
have responsibility for, this address to you this morning is likely 
to be the easiest. 

Having been privileged to be a member of the Executive Com- 
mittee of the Agency’s Executive Board for the past four years, I 
am in a strong position to know what Dr. Carl Kupfer has coped 
with, the personality and enquiring scientific mind he has brought 
to this Agency’s probing of its own capabilities, and the support 
he has given to the network of NGO Members that has developed 
during the eight years of his Presidency — all this with consummate 
ease and against the background of being Director of the National 
Eye Institute of the United States of America. On your behalf, then, 
I thank Dr. Kupfer for all the efforts and planning of those years 
and, conscious of the strength that a marriage brings to one’s part- 
ner’s capacity to serve, I would also like to express our apprecia- 
tion to Kim, who is a highly dedicated member of the ophthalmic 
profession in her own right. 

Someone who shall be nameless once told me that when a 
younger Carl Kupfer came to decide on his career, his deep love 
of music and exceptional ability to play the trumpet nearly took 
him on a different path. I am glad, for the Agency’s sake, that 
ophthalmology triumphed. 

Turning now to the future, you might expect that, raised in the 
heritage of the first President and working closely in IAPB affairs 
with the second, I have a strong sense of the Agency’s philosophical 
core and the transference of that into practical forms of implemen- 
tation through its constituent organizations and individual members. 
It was in 1984 that a small group of NGOs meeting in the WHO 
headquarters in Geneva decided very firmly that if the IAPB had 
not existed at that time, it would have been necessary to create it 
and ensure that it would provide strong long-term support to the 
WHO Program. 


299 


300 Plenary Session VI— I APB Business Meeting 

I said earlier this week that we had to formulate a domestic 
agenda consonant with the theme of this Assembly— prioritizing 
our objectives, enhancing the unique relationship between this re- 
markable cocktail of ophthalmologists, health planners, and NGOs, 
and taking a further step forward in advancing the work of regional 
and national committees. It will be my task to lead the Agency in 
formulating and implementing that agenda, together with ad- 
vocating those sustainable strategies which you all have had a hand 
in identifying during this Assembly. 

I thank you for the confidence you have expressed in my ability 
to undertake the role of President — I feel deeply honored and pledge 
my fullest support to the next four years of the Agency’s work. Im- 
portantly to me with my deep faith in the ability of men and women 
to come together from different nations and cultures in that task, 
I have a strong team in the Executive Board and Regional Chairmen, 
many of whom I have worked with and respected for years — none 
more so than the President-Elect, Dr. Pararajasegaram. 

I take this opportunity to wish you all a safe return to your homes 
and thank you in advance for your support over the next four years. 


PART 



Workshop 

Sessions 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 






■ 








































1 


First Workshop Session — 
Manpower Development 

Prof. Gordon J. Johnson 


Each level of manpower is discussed under the headings of: 

Job description; 

Recruitment; 

Training, including standards and location; 

Numbers; and 

Support, including external sources. 

Some of these topics, and particularly the job descriptions, have 
been thoroughly discussed and documented in the WHO Sub- 
regional Workshop on Manpower Development in Accra, 1988. 


OPHTHALMOLOGISTS 
Job Description 

Ideally, the ophthalmologist should be the team leader of all the 
other eye-health professionals, especially if competent in manage- 
ment skills. 

Recruitment 

The problem of recruiting ophthalmologists who will practice in 
rural areas is common to many countries. Selection of medical 
students is usually based entirely on examination results from 
schools with no consideration to where the applicants plan to 
practice. Solutions include recruiting candidates for training from 
rural areas, and — as in Scandinavia — for it to be obligatory that 
part of the ophthalmic training be conducted outside urban areas. 


303 


304 Workshop Sessions 


It is important that undergraduates should receive good teaching 
in ophthalmology to attract them to the specialty, and also for new 
graduates to rotate through ophthalmology in their internship and 
early residency years. There is an opportunity for an undergraduate 
prize to be awarded by national prevention of blindness commit- 
tees in different countries, and even by the International Agency 
for the Prevention of Blindness. This may help attract candidates 
not only into ophthalmology but increase interest in prevention of 
blindness. 

Training 

1. Standards: There was almost unanimous support for 2 levels 
of training. In a number of countries, successful diploma pro- 
grams in ophthalmology have been held for many years. In 
Israel a 2 or 2.5 year diploma course has existed very suc- 
cessfully for the past 28 years side-by-side with a graduate 
course of 4.5 years. In other countries, such as Uganda, In- 
dia, and Zimbabwe, the diploma program is of one- year’s 
duration. It should be possible for the holder of a diploma 
to return to a residency program and complete the fellowship 
with further training if they wish. This is not at present possi- 
ble in all countries having the two levels of training. 

2. Location : It was recommended that training should take place 
in the ophthalmologist’s own country, or at least in his sub- 
region. Future medical school professors may well need to 
go outside the country for more sophisticated training. The 
value of links between training institutions in Africa with 
similar but more sophisticated institutions in the West was 
emphasized. And the importance of continuing medical 
education was highlighted. 

Numbers 

This would depend on the national plan and would vary from coun- 
try to country. This was considered the province of the health 
planner. 

Support 

It was agreed that attractive, sustainable incentives should be 
developed. It was resolved that the National Committee for the 


Manpower Development 305 


Prevention of Blindness should push for these. Examples already 
in place included tax-free salaries in polar regions, safari allowances, 
and per diem. It is important not to rely on supplements from a 
foreign non-governmental organization, which might have to ter- 
minate support at short notice. 


NON-OPHTHALMIC CATARACT SURGEONS 

The working group did not favor cataract technicians who did not 
have any other training in ophthalmology. They were ambivalent 
to the idea of general practitioners being trained to do cataract 
surgery. The solution of the diploma program that provides train- 
ing in other aspects of ophthalmology as well as cataract surgery 
was much preferred. In certain countries there is an important role 
for ophthalmic assistants who, in addition, have been trained as 
cataract surgeons. 


AUXILIARY SUPPORT 

Objections were made to the name “auxiliary.” Alternative sugges- 
tions were “other team members” or “other eye workers.” It was 
noted that all these cadres of professionals should work under super- 
vision and not independently of the ophthalmology profession. 
These cadres of personnel include: 

1. Community eye-health workers; 

2. Integrated eye-care workers; 

3. Ophthalmic assistants, including ophthalmic nurses; 

4. Optical staff: optometrists, ophthalmic opticians, and op- 
tical technicians (who are not discussed in detail). 

COMMUNITY EYE-HEALTH WORKER 
Job Description 

This person should be a member of the community where he or 
she works. The tasks of the community eye-health worker include 
health promotion (encouraging face washing and giving nutrition 
education), blindness prevention, (prophylaxis in new-born babies 
and by immunization), and curative work (such as giving tetracycline 
ointment and referring serious eye problems). 


306 Workshop Sessions 

Recruitment 

Recruitment depends on whether the workers are paid and this is 
the decision of the individual country. Usually they are chosen by 
the community and in some countries they may have to be approved 
by the chief. 

Training 

This should be as simple and practical as possible and close to the 
person’s residence or place of work. It should not occupy more than 
one week. Most vital is teaching how to identify a blind person. 

Support 

A simple antimicrobial agent, vitamin A, and a visual acuity chart 
are needed. The maintenance of these supplies and equipment is 
essential. Community eye-health workers are supervised by the 
nearest available ophthalmic medical assistant or ophthalmic nurse. 


INTEGRATED EYE-CARE WORKER 

This group includes any health worker who has had some formal 
medical training and who, during the course of his or her routine 
work, is required to see eye patients. It includes nurses, medical 
assistants, and general practitioners doing routine medicine. 

Job description 

They carry out basic examinations of the eye, diagnose, and treat 
common causes of acute red eye. They should refer cataract, cor- 
neal problems, and other serious eye conditions to ophthalmologists. 

Training 

Training should be part of the normal curriculum, so that all health 
workers have the potential to become integrated eye workers. If they 
are already in post, they should, if possible, have a week-long in- 
service seminar. It was established that repeated training or repeated 
short seminars are more effective than a single long exposure. An 
ideal is have two courses, each of one week’s duration, separated 
by six months. 


Manpower Development 307 


Support 

They need supplies and equipment to examine and treat eye patients 
and supervision by the nearest ophthalmologist or ophthalmic 
assistant. 

OPHTHALMIC ASSISTANTS 
Job Description 

Ophthalmic assistants are qualified nurses or medical assistants who 
have had several years of experience in medical work before they 
are selected for specific training in ophthalmology. In some coun- 
tries it is difficult to get the title of ophthalmic medical assistant 
recognized for purposes of pay and there may be difficulty in per- 
suading policy makers to give these people a promotion. In rural 
Africa the ophthalmic assistant is the key person in providing eye- 
care services. A good name in some situations for a nurse eye worker 
is “ophthalmic nurse clinician.” 

The ophthalmic assistant should be able to diagnose and manage 
or refer all routine eye problems, perform eyelid surgery and other 
external procedures, organize and run outreach clinics, and provide 
training and supervision for other levels of personnel. 

Training 

The one-year training course is carried out in a number of centers. 
The Malawi training program takes 20 people a year but has far 
too many applicants for the limited vacancies. There will soon be 
similar programs developed in Lesotho and Zimbabwe. In Sudan 
there have been 20 students per class. Selection of the most suitable 
candidates is a problem because there is a wide variation in fun- 
damental ability. 

Support 

It is important that there is a system of incentives and career pros- 
pects. There must be a government program with a formalized struc- 
ture in which the training is recognized. Support includes adequate 
equipment, reliable supplies, and supervision by an ophthalmologist. 

MANAGEMENT 

In general, it was agreed that ophthalmologists do not know much 


308 Workshop Sessions 


about management. In many countries, however, it is the 
ophthalmologist who bears the responsibility for management. 
There are several levels. 

1. The management of programs at the national level is the 
responsibility of the national committee for the prevention 
of blindness. 

2. Day-to-day operational management is the responsibility of 
the ophthalmologist. 

3. At the hospital level, nurses are usually the managers. In a 
country like Kenya, however, there is no specific training 
course for ophthalmic nurses. 

4. In the Onchocerciasis Control Program, there are professional 
managers who carry out procurement of equipment and 
many other similar functions. The ophthalmologists, never- 
theless, must assume leadership. 

5. Most programs cannot afford to pay a professional manager 
at the district level and therefore the ophthalmologists and 
other health workers must carry out management tasks. 


TRAINING 

In a number of courses the teaching of this subject may become 
very theoretical. A course in health administration of three months 
duration is available in Tanzania. Some training in management is 
included as a component in the newer ophthalmic curricula. There 
is also a journal entitled “Ophthalmic Management.” It is still to 
be decided how much management training ophthalmologists re- 
quire. Much depends on who else in the team can be used for some 
aspects of management. 


2 


Second Workshop Session— 

Delivery of Specific Eye-Care Services 

Ms. Victoria M. Sheffield 

The workshop group believed that IAPB should take a regional ap- 
proach when making recommendations. 


RECOMMENDATIONS: 

1. Service delivery should be appropriate to the personnel 
available and to the infrastructure. 

2. With regard to personnel, the ophthalmologist should play 
a leadership role in the area of prevention as well as clinical 
services. The ophthalmologist should also be a leader with 
regard to organization and management. Eye-care services 
can be delivered by two cadres of workers: 

Ophthalmic Medical Assistants (OMA) 

General OMAs 
OMA/Cataract Surgeons 
Ophthalmic Nurses 

Multipurpose Workers General 
General Physicians 
Nurses 

Health Assistants 
Community Health Workers 

Ophthalmic-health workers are valuable in recognizing, treating, 
and/or referring conditions needing ophthalmic care and providing 
prevention education for common eye conditions. Multipurpose 
workers have a major role in health education and community 
awareness about eye conditions and how to prevent them. In general, 
the group felt that eye-care service delivery should have two major 
components: 


309 


310 Workshop Sessions 


Multipurpose Prevention 

Vitamin A Deficiency Control 
Onchocerciasis Control 

Support for Expanded Program on Immunization (EPI) 
Promotion of Face Washing to Control Trachoma 
Awareness of Harmful Eye Practices 
Community Education 

Specific Curative 

Reduction of Cataract Blindness 
Treatment of Corneal Ulcers 
Trichiasis/Entropion Surgery 
Treatment of Glaucoma 
Treatment of Trauma 
Treatment of Refractive Error 
Treatment of Leprosy 

MULTIPURPOSE PREVENTION 
Vitamin A Deficiency Control 

All eye-care programs in developing countries must include the treat- 
ment and prevention of xerophthalmia. 

Recommendation: All children with measles should receive vitamin 
A to prevent blindness and reduce the risk of mortality. 

Onchocerciasis Control 

Current programs hope to provide Ivermectin to all those living in 
hyperendemic areas who are at risk of blindness. 

Recommendation: Ivermectin distribution programs should employ 
simple screening methodologies to determine hyperendemic areas 
for targeting expanded distribution of Ivermectin. 


Support for Expanded Program on Immunization (EPI) 

The group was emphatic in their support for EPI programs. 

Recommendation: All eye-care programs should support in all ways 
possible the promotion of EPI, especially measles vaccination. EPI 
vaccinators should be trained in the recognition, treatment, and 
prevention of xerophthalmia. 


Delivery of Eye-Care Services 311 


Promotion of Face Washing to Control Trachoma 

Eye-care programs which include trachoma control should em- 
phasize the following four main points. 

Recommendations: 

1. Programs should employ the new WHO/PBL Trachoma 
Grading Scheme. It is simple, in use, and reproducible. 

2. Health workers and the public should be taught the impor- 
tance of reinfection and how this must be prevented. 

3. Community education in the control of trachoma should be 
a major activity. The importance of personal hygiene should 
continue to be stressed. 

4. Ophthalmic medical assistants should all be proficient in the 
performance of surgery to correct trichiasis and entropion. 

Awareness of Harmful Eye Practices 

Eye-health education programs should include messages that discuss 
the common causes of eye injuries in the area. Additionally, educa- 
tion messages should address harmful traditional practices that are 
known to be used in the area and which causes eye injuries. 

Recommendation : Eye health education messages should address 
the common causes of eye injuries in the area including harmful 
traditional practices. 

Community Education 

All eye health programs should have a strong community educa- 
tion component whether the teaching activities take place in a clinic 
or out in the community. Recommendations for specific eye health 
education messages are listed under other headings as appropriate. 


SPECIFIC CURATIVE 

Reduction of Cataract Blindness 

Recommendations: 

1. In countries where there are enough ophthalmologists to care 
for the population, ophthalmologists should be equitably 
distributed within the Ministry of Health System. 


312 Workshop Sessions 


2. In areas where there are not enough ophthalmologists, an 
ophthalmic medical assistant/cataract surgeon cadre should 
be developed. Visiting surgeons who conduct cataract cam- 
paigns on a short-term basis should not be seen as substitutes 
for a cadre of cataract surgeons, but rather simply for the 
purpose of service delivery and teaching to develop a long- 
term solution. 

3. Where there are neither ophthalmologists nor ophthalmic 
medical assistants, as is often the case on small islands, 
vo unteer ophthalmologists making short-term visits are 
appropriate. 

4. With regard to intraocular lenses, it is recommended that 
IOLs be used where the surgical and postoperative environ- 
ment are appropriate. Part of this consideration is that the 
IOLs should be affordable either by the patient or by the 
health system. 

5. IOLs are not recommended for use in children. 

6. Outpatient surgery with local anesthesia should be encour- 
aged whenever possible and wherever appropriate. 


Treatment of Corneal Ulcers 

Recommendations: 

1. Children with clinical vitamin A deficiency who are at risk 
of blindness should be treated with vitamin A according to 
the treatment schedule recommended by the World Health 
Organization. Their caretakers also should be provided with 
appropriate information on the importance of feeding vita- 
min A-rich foods concurrently with treatment and there- 
after— and not only to the affected child but also to other 
children within the family. 

2. In countries where surgeons are trained to perform ker- 
atoplasty, governments should be urged to enact coroners laws 
to allow surgeons to remove corneal tissue for transplantation. 


Trichiasis/Entropion Surgery 

Recommendations under this heading are similar to those listed 
under face washing and trachoma control. Specifically, it is recom- 


Delivery of Eye-Care Services 313 

mended that OMAs be proficient in performing trichiasis/entro- 
pion surgery. 

Treatment of Glaucoma 

In developing countries, chronic open-angle glaucoma is difficult 
to diagnose. It is often virulent and holds socioeconomic impor- 
tance because it affects young, productive adults as well as the 
elderly. When referrals come, they usually come from three groups: 

1. general practitioners, 2. ophthalmic medical assistants or 
ophthalmic nurses, and 3. opticians or optometrists. 

Recommendations: 

1. Teach tonometry to ophthalmic medical assistants. It is not 
necessary to convert the tonometer reading into millimeters 
of mercury. The assistant should simply record the reading 
seen on the scale. 

2. Ophthalmic medical assistants should also be taught to ex- 
amine the anterior chamber from the side with an electric 
torch to examine for closed-angle glaucoma. 

3. Screening should be limited to high-risk groups because of 
limited resources and the fact that services must be available 
to glaucoma patients who are identified. 

Treatment of Trauma 

Recommendations: 

1. Identify the leading causes of eye injury in the local area or 
region. 

2. Community education messages should include information 
about the leading causes of blindness due to trauma and how 
to prevent them. 

3. Because many eye injuries are caused at work, community 
education should also take place in industry. 

4. Community education should especially target children to 
teach them about the dangers that can injure their eyes and 
how to prevent them. 

Treatment of Refractive Error 

Recommendations: 

1. Eye-health programs should have as a component the 


314 Workshop Sessions 

development and maintenance of a low-cost spectacle 
workshop scheme. 

2. Screening for refractive error can be done when spectacles 
are available and affordable to those being screened. 

Treatment of Leprosy 

Recommendation: Leprosy patients should be allowed into the 
general eye clinic for clinical treatment and surgery. 


GENERAL RECOMMENDATIONS 

1. Steroid medications should not be used in the eye except by 
an ophthalmologist or trained ophthalmic medical assistant. 

2. There should be a major effort on the part of IAPB and its 
members to maximize eye-care services and facilities already 
available. 

3. The development of schemes for the local production of eye 
drops should be encouraged. 

4. The IAPB should work with regional and local representatives 
to create incentives that would encourage ophthalmologists 
to work in rural areas. 


3 


Third Workshop Session— 

Major Challenges and Priorities 
for the Delivery of Eye-Care Services 


ANGLOPHONE WORKSHOP REPORT 

Dr. Bjorn Thylefors 

The overall challenge is slowing the growth of blindness as a public 
health and socioeconomic problem. The specific challenges to be 
tackled include: 

1. Limited access to eye care, including both primary eye care 
and, perhaps even more, the delivery of eye care at the secon- 
dary level. There are three areas of concern in this context: 
urbanization and creation of slum areas; population growth, 
which is very pronounced in many developing countries; and 
the increasing number of elderly, who are particularly in need 
eye care. 

2. Need to strengthen national blindness prevention programs. 

3. Need to maintain the priority and visibility of blindness 
prevention in order to secure the allocation of resources for 
a sustainable program. 

4. Insufficiency of resources, facilities, and proper equipment, 
including ophthalmic drugs. 

To address the challenge of limited access to eye care, emphasis 
must be placed on the inception and strengthening of primary eye- 
care programs. The training of auxiliary personnel in eye care at 
community and district levels is the next priority. At the province 
level, there must be available, depending on the setting, a sufficient 
number of ophthalmologists or cataract surgeons. The distribution 
of manpower should be considered in relation to administrative 


315 


316 Workshop Sessions 

units, not only in total numbers for a country. The recommended 
criteria for personnel should be fulfilled: 1 ophthalmologist per 
500,000 population; 1 cataract surgeon per 250,000 population; and 
1 ophthalmic assistant or ophthalmic nurse per 100,000 population. 

Other problem-solving proposals include promotion of team- 
work and improved communications between medical staff and 
other sectors. Management must be introduced in all programs at 
the various operational levels. 

With regard to manpower development, task-oriented training 
and a more flexible posting of staff between rural and urban areas 
must be given priority. Considering general population growth and 
the increasing number of elderly in all populations, planning must 
begin now for the situation in the year 2000, particularly for needed 
manpower and for cataract surgery. 

To improve access to eye care in urban slums, primary health 
care again must be the main strategy. Work through other health 
programs, such as the Expanded Program on Immunization and 
Maternal and Child Health may be useful in some situations. It 
is important that the consumer’s point of view concerning ap- 
propriate and acceptable eye care is always taken into account. 

The first priority for strengthening national programs is to en- 
sure the political will and commitment of the community. There 
must be clearly identified objectives and targets established for the 
program; and they must be meaningful to politicians and to the 
public, as well as being technically sound. 

In many countries where primary eye care needs to be strength- 
ened there is still a shortage of resources for the secondary level 
of eye care. The involvement and experience of local and interna- 
tional non-governmental organizations (NGOs) can be particularly 
useful in solving these problems. The NGO involvement should flow 
through the national committees once a planning process has been 
initiated to make the NGOs true partners in a developmental process. 

One often-neglected source for manpower and public education 
is the local teaching staff at universities and other educational in- 
stitutions. Another area in need of intensified efforts is program 
evaluation, which should be done periodically with the participa- 
tion of NGOs. 

In addition, the process of strengthening a national program 
should include the integration of program activities into general 
health care only after the program has been fully operational and 
has gained experience. This integration should be achieved in phases 


Challenges and Priorities for Delivery of Eye-Care Services 317 

in accordance with mutual agreements between the Ministry of 
Health and the NGOs. 

To tackle the problem of maintaining blindness prevention as 
a priority for resource allocation, the following points may be 
considered: 

1. A political lobbying system that stresses the importance of 
blindness prevention to decision-makers is helpful. Clear 
messages about what is needed, what is feasible, and what 
should be done immediately are vital. 

2. The presentation of sound program activities with a clear- 
cut plan and rationale is important. 

3. Having regularly available information about blindness 
prevention in general, and on specific ongoing activities is 
a must. 

4. Making available the evaluation of achievements, including 
the impact of saving or restoring sight in relation to social 
and economic developments can lead to fruitful results. 

The general insufficiency of resources for blindness prevention 
in many developing countries can be tackled in a multitude of ways, 
such as: 

1. Sound program planning; 

2. A good management (and expenditure) system; 

3. Manpower development with emphasis on auxiliary staff and 
delegation of tasks; 

4. Community participation; and 

5. Low-cost technology, with standardization of equipment and 
supplies. 

To illustrate the above points, the particular case of a sustainable 
cataract intervention program was considered in more detail. 

CHALLENGE: To deliver cataract surgery to all those in need. 

Proposed solutions: 

1. Better use of ophthalmologists’ time for cataract surgery and 
more practical training during residency; 

2. Training of cataract surgeons on a task and performance 
basis; 


318 


Workshop Sessions 


3. Outpatient cataract surgery whenever possible; 

4. Standardization of surgical procedure, equipment, and sup- 
plies needed, as well as a central purchasing arrangement, 
to which NGOs may contribute through their nonprofit pur- 
chase channels; 

5. Case-finding at the community level, as part of primary eye 
care; 

6. Overcoming socioeconomic barriers through public informa- 
tion and active community support; promotion by success- 
fully operated cases; 

7. Management and evaluation of achievements, in relation to 
objectives and targets set, also considering cost-effectiveness; 

8. Appropriate, but low-cost technology, including aphakic spec- 
tacles and the local production of eye drops. 


FRANCOPHONE WORKSHOP REPORT 

Dr. Patrick Quequiner 

The group from French-speaking countries set themselves the ob- 
jective of defining the challenges and the constraints, encountered 
in the context of Sub-Saharan Africa, for the improved delivery of 
eye care in the future. 

The primary objective is to make eye care accessible to all by 
the year 2000. The constraints encountered in attaining this objec- 
tive have been: difficulties of access to health services; the popula- 
tion explosion and the change in distribution of the population; 
weaknesses in management practices; and the low level of atten- 
tion and priority accorded to prevention of blindness programs by 
governments. 

The proposals made to remove these obstacles are: 

1. Establish an effective primary eye-care delivery system. 

To achieve this, emphasis should be placed on training auxiliary 
personnel at the primary level for community and district hospital 
work. At the secondary level, the hospital should have a team 
at its disposal, including a fully trained ophthalmologist. 

Dr. Allen Foster’s proposed goals of 1 ophthalmologist per 
500,000 inhabitants, 1 cataract surgeon per 250,000 inhabitants, 


Challenges and Priorities for Delivery of Eye-Care Services 319 

and 1 specialized nurse per 50,000 inhabitants appear to be 
realistic and designed to achieve the objectives accepted by the 
group. 

The training of medical and paramedical personnel must be 
oriented towards those skills necessary to deal with specific eye- 
care problems. 

The present distribution of medical personnel, which is con- 
centrated in urban centers, is not rational. It will be necessary 
to persuade appropriate personnel to accept the types of 
ophthalmic exercises recommended: first by developing training 
courses in the use of public health methodology, and sub- 
sequently by improving the range of opportunities for person- 
nel, including developing new methods of technical assistance 
and designing relevant career profiles. 

At the end of the training period, each student should be 
integrated into the health system in an appropriate location and 
provided with the necessary equipment to carry out the tasks 
for which he or she has been trained. Equipment must be pro- 
vided and suitable training must take place. In addition, the team 
that the student will lead must be organized at the outset of 
training. 

2. In response to the population explosion and to the new distribu- 
tion of this population, in particular to the concentration around 
large cities, it will be necessary to: 

• Assess training needs and the provision of health services 
based on available demographic projections for the year 2000 
and not on the existing figures. 

• Ensure that account is taken not only of eye-care service 
delivery but also of other programs, such as EPI, and mother 
and child clinics. 

• Prepare for growing requirements in the field of geriatric 
ophthalmology. 

• Adapt services to respond to the emergence of new demands 
in the ophthalmic field, including diabetic retinopathy and 
macular degeneration. 

• Develop a better understanding of specific ocular problems 
and the provision of medical services in peri-urban zones, 
including shanty towns. 


320 Workshop Sessions 


3. To revive and reinforce programs in the fight against blindness, 
the Francophone group discussed weaknesses of the management 
process and considered that methods of planning and evalua- 
tion needed to be considered. 

• Evaluation should take place after every phase and every 
stage of the program, with particular attention paid to 
cost-effectiveness. 

• Participating NGOs should be included and should be ready 
for renegotiation in the light of this experience and should 
collaborate in the extension or consolidation of the program. 

• The program should be tried and tested before integration 
takes place; and, in any event, the program director should 
stay close. 

• The competence of NGOs should be used in areas in which 
they are expert, such as the training of personnel or the 
developing of primary health-care services. 

4. To maintain high-quality, high-priority programs in the fight 
against blindness, planners and national health authorities must 
deliver a message that is clear, coherent, and acceptable by all 
the participants in the program. Their arguments, particularly 
on cost-effectiveness, must be well-reasoned and very convincing. 


Two examples were then chosen by the group: the treatment of 
cataract and the distribution of Ivermectin. 


4 


Fourth Workshop Session— 

Essential Characteristics of a 
Model Self-Sustaining Program 

Mr Kevin Carey 

PANEL DISCUSSION ON COMMUNITY-BASED 
REHABILITATION WORKSHOP REPORT 

Services for incurably blind people can be divided broadly into three 
types: education and counselling services for children and their 
families; vocational and rehabilitation services for blind people who 
could be expected to be active in paid or unpaid employment; and 
services for blind people with additional disabilities and/or those 
who are past working age. 

When a child is diagnosed as incurably blind, concentrate on 
the forthcoming challenge to its parents. Ensure that advice is: 

1. coherent and not in conflict with others in the medical team; 

2. realistic , particularly in terms of the prognosis, because faint 
hopes or “miracle cures” can often hamper the process of 
adjustment to blindness; 

3. encouraging by emphasizing that blindness is strictly a limited 
disability and not a tragedy; and 

4. practical , establish where the parents should go for further 
assistance. 

A blind child is a child first and blind second; not the other 
way around. 

Most people who go blind in middle or late life can continue 
with many of their activities, but they will require a huge amount 
of encouragement and probably a modest amount of technical 
assistance and support. Being blind subjects people to a constant 
stream of minor technical problems that need to be overcome. The 


321 


322 Workshop Sessions 


importance of residual vision can not be over-emphasized, 
particularly because it is still widely believed that residual vision 
should be “conserved” and not used. 

In developing countries there is usually some form of special 
education available for blind children; if provision is inadequate 
it is important to refer the child for the service so that demand for 
the service is created. Most countries have organizations of or for 
the blind dealing primarily with services for incurably blind adults 
and although their activities are often confined to capital cities, 
again, referral for the purposes of demand creation is important. 

Where there are no special services, there is much that the blind 
person, his/her family, and the community can do to improve the 
situation. Economic activity for those of working age is important 
but the key concepts are dignity, respect, and participation — and 
all of these are possible for a blind person without the assistance 
of specialized agencies. 

Two positive recommendations grow out of this discussion: first, 
all eye-care workers should receive basic instructions on the way 
incurably blind people function and should know about special ser- 
vices and registration procedures; secondly, emphasis in diagnosis 
and prognosis should be on the whole person and family rather 
than being merely a narrow consideration of ocular pathology. 


PART 9 


Banquet 
and Awards 
Ceremony 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 



1 


IAPB Lifetime Awards 

presented at the Fourth General Assembly 

PROF. ANTOINETTE PIRIE 

Following an illustrious career in the biochemistry of the visual 
system, Professor Pirie occupied the Nuffield Chair in Ophthal- 
mology at the Radcliffe Eye Hospital and Oxford University. 
Professor Pirie then turned her research efforts to the challenge of 
blinding malnutrition and launched a new career in which she com- 
bined laboratory animal research with clinical field work in India. 
In so doing, she developed new laboratory tests to determine high- 
risk children. In addition, she created new strategies to provide nutri- 
tion education to parents of affected children so that upon their 
return to the village, these parents would influence the eating prac- 
tices within the village so that all parents would provide a diet rich 
in vitamin A. The legacy of this work lives on in many locations 
in southern India. Dr. Antoinette Pirie’s strategy of nutrition educa- 
tion and kitchen gardens, developed almost two decades ago, has 
now become one of the major approaches to the problem of blind- 
ing malnutrition. 


DR. VIGGO CLEMMESEN 

With the inception of the IAPB in 1975, Dr. Clemmesen expanded 
his Denmark-based prevention of blindness activities and focused 
on Scandinavia and subsequently the entire world. In his capacity 
as Registrar of the IAPB, he has devoted hundreds of hours of 
unreimbursed effort to help us build a strong association of na- 
tional committees. In so doing, he has imbued the IAPB with a 
sense of commitment to the worldwide fight against avoidable blind- 
ness. Dr. Viggo Clemmesen clearly exemplifies how one person’s 
contributions can make a major difference in global prevention of 
blindness programs. 


325 


326 Banquet and Awards Ceremony 

DR. MOSES C CHIRAMBO 

Dr. Chirambo’s collaboration with the late Prof. Isaac Michelson, 
which began two decades ago, has led to the establishment of the 
Southern African Regional Training Centre in Malawi, where he 
has developed a curriculum for primary eye care and trained scores 
of ophthalmic auxiliary personnel. Perhaps even more impressive 
has been the leadership by example that he has provided to much 
of the African continent. Primarily through the assiduous efforts 
of Dr. Moses Chirambo, one of the foremost ophthalmologists in 
the developing world, prevention of blindness projects are increas- 
ing more rapidly in Africa than in any other region of the globe. 

DR. FRANCISCO CONTRERAS 

One of the early pioneers in prevention of blindness in Latin 
America, Dr. Contreras has established a program in Peru that has 
become a model for other countries in that region. His program 
includes training village health workers to detect major eye path- 
ology, enhancing the capabilities of ophthalmic assistants by teach- 
ing them how to give more detailed eye examinations and how to 
provide simple treatment, and developing ophthalmologists in the 
excellent residency program in his hospital. His recent successes in 
implementing the Cataract-Free Zone concept, his organizing a 
National Eye Institute in Lima, and his outstanding leadership as 
Executive Director of the Pan-American Association of Ophthal- 
mology clearly identify Dr. Francisco Contreras as an extraordinarily 
effective long-time leader in community ophthalmology. 

DR. CHENG HU 

A true disciple of Drs. Eugene Chen and Winifred Mao, Dr. Cheng 
Hu has continued and expanded the tradition of community 
ophthalmology in China. With the first scientifically designed prev- 
alence survey in the mid-1980s, he has drawn the attention of the 
Chinese Ministry of Health to the magnitude of the blindness prob- 
lem in his country. In addition, Dr. Cheng Hu has been the primary 
catalyst in organizing the National Committee for the Prevention 
of Blindness in China and has brought that Committee into 
membership within the International Agency for the Prevention of 
Blindness. 


I APB Lifetime Awards 327 


DR. RABIUL HUSAIN 

With exceptional skill, Dr. Rabiul Husain has harnessed the ex- 
traordinary external resources that have been made available in 
Bangladesh and has established an outstanding training and out- 
reach facility for the delivery of eye care in the Chittagong region. 
The construction of the Chittagong Eye Infirmary and Training 
Complex has made us all aware of the dedication, initiative, and 
energy that Dr. Husain has brought to prevention of blindness ac- 
tivities in Bangladesh. The Chittagong Complex offers training 
courses for physicians and ophthalmic paramedics and has become 
a superb model of community ophthalmology for South-East Asia 
and other parts of the world that share the common problems of 
eye care delivery. What is particularly exceptional is that Dr. Rabiul 
Husain has accomplished this in a remarkably short period of time 
and in a manner that has maintained the highest standards of safety 
and efficacy in patient care. 


MR. ISMAILA KONATE 

Mr. Ismaila Konate, the current president of the Mali National 
Union of the Blind, was the founder and principal force behind 
the development of educational and social work for the blind in 
Mali. He has also been a leading member of the national organiza- 
tion for the prevention of blindness in Mali, and he is president 
of the African Union of the Blind, which is the African regional 
component of the World Blind Union. Mr. Ismaila Konate is one 
of the truly outstanding leaders in the effort to eradicate avoidable 
blindness. 





















































PART 10 


Appendices 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 



Appendix A 


National Delegates to the 
Fourth General Assembly 


Each of the following 113 people from 60 countries was nominated 
by his or her Ministry of Health or national prevention of blind- 
ness committee and accredited by the IAPB Executive Board to be 
a “national delegate” to the Fourth General Assembly. These 
delegates were thereby authorized to vote on behalf of their national 
committees on any special resolutions at this General Assembly’s 
Business Meeting. 

According to Article VI of the IAPB Constitution: “National 
delegates may be appointed from any country in which there exists 
a national committee or national organizations (or any approved 
grouping of such committees and organizations) recognized by the 
Executive Board as entitled to appoint that country’s national 
delegates. The Executive Board may withhold such recognition if 
it considers that the nominating committee, organization, or group 
is insufficiently representative of the organizations and interests con- 
cerned with the prevention of blindness in that country. 

“The number of national delegates which may be nominated 
for appointment from any country shall be related to the size of 
that country’s population as revealed in the most recent national 
census. A country with a population not exceeding 5 million may 
appoint one delegate. A country with a population of more than 
5 million but not exceeding 20 million may appoint two delegates. 
A country with a population of more than 20 million but not ex- 
ceeding 50 million may appoint four delegates. A country with a 
population of more than 50 million may appoint six delegates.” 

Article IX, Section 2, states: “Only national delegates, inter- 
national delegates, and members of the Executive Board may vote 
on a special resolution as defined in Article VIII, Clause 3, of this 
Constitution.” 


331 


332 Appendix A 


The latter article defines a special resolution as one that con- 
cerns: (a) the amendment of the Constitution; (b) the number of 
members in each group of the Executive Board and the election 
of members in Groups A, B, C, and E of the Board; (c) approval 
of the financial estimates of the Agency; and (d) the dissolution 
of the Agency. 

Article IX, Clause 6, states: “A national delegate who is unable 
to attend a session of the General Assembly may authorize another 
member of his national delegation to exercise a proxy vote on his 
behalf.” 

The following is a list of those delegates who were in attendance 


or who used a proxy at the Fourth General Assembly Business 

Meeting. 

Australia 

Chile 

Dr. Frank Billson 

Dr. Rene Canovas Emhart 

Dr. Henry S. Newland 

Dr. Eugenio Maul 

Dr. Hugh Taylor 

China 

Bangladesh 

Dr. Cheng Hu 

Begum Raushan Ershad 

Dr. Wenbin Lo 

Dr. Rabiul Husain 

Dr. Sun Bao-chen 

Prof. M.A. Matin 

Dr. Zikuan Zhang 

Mr. Abu Baker Siddique 

Colombia 

Belgium 

Dr. Virgilio Galvis 

Dr. Jean-Paul Herbecq 

Denmark 

Botswana 

Dr. Ernst Goldschmidt 

Dr. Kealeboga Makhwade 

Ethiopia 

Brazil 

Dr. Pawlos Quana’a 

Dr. Alzira Nicolini Delgado 

France 

Dr. Newton Kara-Jose 

Gen. Marcel Chovet 

Burkina Faso 

Dr. Pierre Huguet 

Dr. Virginie Tapsoba 

Prof. Patrick Queguiner 
Dr. Serge Resnikoff 

Cameroon 

Dr. Theodosia E. McMoli 

Gambia 

Dr. Hannah B. Faal 

Canada 

Dr. A.T. Jenkyns 
Ms. Maureen McManus 

Germany 

Dr. Volker Klauss 


Ghana 

Central African Republic 

Dr. Maria Hagan 

Dr. A. Auzemery 

Dr. J.D. Otoo 


National Delegates to the Fourth General Assembly 333 


Guatemala 

Rosa Amalia de Vasquez 
Dr. Fernando Beltranena 

Guinea 

Dr. Adiatou Sylla 

India 

Dr. R. Jose 
Dr. S.R.K. Malik 
Dr. Anita Panda 
Dr. P. Siva Reddy 
Dr. H.K. Tewari 
Dr. G. Venkataswamy 

Indonesia 

Dr. Bambang Hamurwono 
Dr. Istiantoro 

Israel 

Dr. Lutza Yanko 

Japan 

Dr. Atushi Kanai 
Dr. Kazuichi Konyama 
Dr. Akira Nakajima 
Dr. Kenji Yanashima 

Kenya 

Prof. Henry S. Adala 
Dr. A.K. Gikonyo 
Dr. Ashok K. Shah 
Mr. Samuel K. Tororei 

Lao People’s 
Democratic Republic 

Dr. Vithoune Visonnavong 

Lesotho 

Dr. Musi Mokete 
Dr. F. Rathabaneng 

Madagascar 

Dr. Rakotomalala Mireilli 


Malawi 

Dr. Moses C. Chirambo 

Mali 

Mr. Ismaila Konate 
Mr. Moussa Bado 

Morocco 

Dr. Youssef Chami Khazraji 

Mozambique 

Dr. Yolanda T.D.C. Zambujo 

Myanmar 

Dr. Tun Aung Myaw 
Nepal 

Dr. R.P. Pokhrel 
Dr. S.P. Lakhey 

Netherlands 

Dr. J.S. Stilma 

Nigeria 

Prof. Adenike Abiose 
Dr. U.F. Ibrahim 
Prof. A.A. Majekodumni 
Dr. Chito Obowu 

Norway 

Dr. Oddvar Otterlei 

Pakistan 

Dr. Jamshed Wania 

Papua New Guinea 

Dr. Bage Yaminao 

Peru 

Dr. Francisco Contreras 

Philippines 

Dr. Ronaldo A. Paraan 


334 Appendix A 


Saudi Arabia 

Sheikh Abdullah M. 

Al-Ghanim 
Mr. Saleh Abdullah 
Al-Majid 

Senegal 

Prof. Joseph Diallo 

Sierra Leone 

Dr. Aveline Horton 
Dr. D. Williams 

Singapore 

Dr. Lim Kuang Hui 
Somalia 

Dr. Mohamed A. Shilkey 

Spain 

Dr. Elvira Martin 
Mr. Antonio Martinez 
Mr. Rafael Mondaca 

Sri Lanka 

Dr. M.R.L. Perera 
Dr. Tilak Thinasiaghe 

Sudan 

Dr. Hadi Elsheikh 
Dr. K. Mohammed 

Sweden 

Dr. Elisabeth Aurell 

Tanzania 

Dr. Walter Jana 
Dr. S.B. Katenga 
Dr. N.N. Kinabo 
Mr. William Mindolo 


Thailand 

Dr. Suchint Phalakornkule 
Dr. Emorn Udomkesmalee 

Tunisia 

Dr. Ahmed Trabelsi 
Turkey 

Dr. Fiisun Sayek 

Uganda 

Dr. K. Mushega 

United Kingdom 

Mr. Alan W. Johns 
Prof. Gordon J. Johnson 
Sir John Wilson 
Lady Wilson 

United States 

Dr. Suresh Chandra 
Mr. Oliver Foot 
Dr. Suzanne Gilbert 
Ms. Meredith Lloyd 
Prof. Alfred Sommer 
Dr. Barbara A. Underwood 

Yemen 

Dr. Ibrahim El-Gorafi 

Zambia 

Mr. David Mwandu 

Zimbabwe 

Mr. W. Sithole 
Dr. S. Guramatunhu 


Appendix B 

World Health Organization 
Regional Offices, Collaborating Centers 
for the Prevention of Blindness, and 
Member Nations by Region 

WHO REGIONAL OFFICES 


World Health Organization 

Regional Office for Africa 

P. O. Box 6 

Brazzaville 

Congo 


World Health Organization 
Regional Office for Europe 
8, Scherfigsvej 
DK-2100 Copenhagen 
Denmark 


Pan American Health 


World Health Organization 


Organization 

Regional Office of the World 


South-East Asia 
World Health House 
New Delhi 1.10.002 
India 


Regional Office for 


Health Organization 
525 23rd Street, N. W. 
Washington, D. C. 20037 
USA 


World Health Organization 
Regional Office for the 
Eastern Mediterranean 


World Health Organization 
Regional Office for the 


P. O. Box 1517 
Alexandria 21511 
Egypt 


Western Pacific 
United Nations Avenue 
P. O. Box 2932 
Manila 2801 
Philippines 


335 


336 Appendix B 


WHO COLLABORATING CENTERS 
FOR THE PREVENTION OF BLINDNESS 

The African Region 

Institut d’Ophtalmologie tropicale de l’Afrique 

B.P. 248 

Bamako 

Mali 

(Director: Dr. Serge Resnikoff) 

The Region of the Americas 

International Center for Epidemiologic 
and Preventive Ophthalmology 
The Dana Center 

The Wilmer Ophthalmological Institute 

The Johns Hopkins School of Hygiene and Public Health 

600 North Wolfe Street 

Baltimore, Maryland 21205 

USA 

(Director: Prof. Alfred Sommer) 

National Eye Institute 
National Institutes of Health 
Building 31, Room 6A03 
Bethesda, Maryland 20892 
USA 

(Director: Dr. Carl Kupfer) 

Dr Rodolfo Robles V Eye & Ear Hospital 
National Committee for the Blind and Deaf 
4a Avenida 2-28, Zona 1 
Guatemala City 
Guatemala 

(Director: Dr. Fernando Beltranena) 

Centro Oftalmologia “Luciano Barrere” 

Santo Toribio de Mogrovejo Hospital 

Jr. Ancash 1271 

Lima 

Peru 

(Director: Dr. Francisco Contreras) 


WHO Offices , Collaborating Centers , Member Nations 337 


Francis I. Proctor Foundation for Research in Ophthalmology 
University of California, San Francisco 
San Francisco, California 94143 
USA 

(Director: Dr. Chandler R. Dawson) 

Servico de Oftalmologia Sanitaria 

Secretaria de Estado da Saude 

Av. Dr Eneas de Carvalho Aguiar No. 188 

8° Andar 

Caixa Postal 8027 

Sao Paulo, S.P. 05403 

Brazil 

(Director: Dr. O. Monteiro de Barr os) 


The Eastern Mediterranean Region 

Institut d’Ophtalmologie 

Bab-Saadoun 

Tunis 

Tunisia 

(Director: Prof. S. Ayed) 

King Khalid Eye Specialist Hospital 
P. O. Box 7191 
Riyadh 11462 
Saudi Arabia 

(Director: Dr. Ihsan A. Badr) 


The European Region 

International Centre for Eye Health 

Department of Preventive Ophthalmology 

Institute of Ophthalmology 

University of London 

27/29 Cayton Street 

London, EC1V 9EJ 

United Kingdom 

(Director: Prof. Gordon J. Johnson) 


338 Appendix B 


Department of Viral and Allergic Eye Diseases 
Helmholtz Research Institute of Ophthalmology 
Sadovaja-Chernogriazslakaj 14/19 
Moscow 103064 
Russia 

(Director: Prof. Y.F Maichuk) 


The South-East Asia Region 

Dr Rajendra Prasad Centre for Ophthalmic Sciences 

All-India Institute of Medical Sciences 

Ansari Nagar 

New Delhi 110016 

India 

(Director: Prof. P.K. Khosla) 


The Western Pacific Region 

Department of Ophthalmology 

Juntendo University School of Medicine 

3-1-3 Hongo 

Bunkyo-ku 

Tokyo 113 

Japan 

(Director: Prof. Atushi Kanai) 

Beijing Institute of Ophthalmology 
Tong Ren Hospital 
2 Chong Nei Street 
Beijing 

People’s Republic of China 
(Director: Dr. Shi-Yuan Zhang) 


WHO Offices , Collaborating Centers, Member Nations 339 

WHO MEMBER COUNTRIES BY REGION 

The 75 countries that have a national prevention of blindness com- 
mittee affiliated with the IAPB are in bold. 


The African Region 

Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, 
Cameroon, Cape Verde, Central African Republic, Chad, Comoros, 
Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, 
Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, 
Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, 
Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, 
Sierra Leone, South Africa, Swaziland, Tanzania, Togo, Uganda, 
Zaire, Zambia, Zimbabwe. 


The Region of the Americas 

Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, 
Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, 
Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, 
Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, 
Panama, Paraguay, Peru, St. Christopher and Nevis, St. Lucia, St. 
Vincent and The Grenadines, Surinam, Trinidad and Tobago, United 
States of America, Uruguay, Venezuela. 


The Eastern Mediterranean Region 

Afghanistan, Bahrain, Cyprus, Democratic Yemen, Djibouti, Egypt, 
Iran, Iraq, Jordan, Kuwait, Lebanon, Libyan, Morocco, Oman, 
Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab 
Republic, Tunisia, United Arab Emirates, Yemen Arab Republic. 


The European Region 

Albania, Austria, Belgium, Bulgaria, Belarus, Czechoslovakia, Den- 
mark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, 
Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, Malta, 
Monaco, Netherlands, Norway, Poland, Portugal, Romania, Russia, 


340 Appendix B 


San Marino, Spain, Sweden, Switzerland, Turkey, Ukraine, United 
Kingdom, Yugoslavia. 


The South-East Asia Region 

Bangladesh, Bhutan, Democratic People’s Republic of Korea, Indi^, 
Indonesia, Maldives, Mongolia, Myanmar (Burma), Nepal, Sri 
Lanka, Thailand. 


The Western Pacific Region 

Australia, Brunei Darussalem, China, Cook Islands, Democratic 
Kampuchea, Fiji, Japan, Kiribati, Lao People’s Democratic 
Republic, Malaysia, New Zealand, Papua New Guinea, Philippines, 
Republic of Korea, Samoa, Singapore, Soloman Islands, Tonga, 
Vanuatu, Vietnam. 


Appendix C 

IAPB Leadership 1990-94 


OFFICERS 

President 

Mr. Alan W. Johns 

Honorary President 

Sir John Wilson 

Immediate Past President 

Dr. Carl Kupfer 

Senior Vice President and President-Elect 

Dr. R. Pararajasegaram 

Vice Presidents 

Dr. Akira Nakajima — (President, International Federation of 
Ophthalmological Societies) 

Mr. Duncan Watson — (President, World Blind Union) 

Rev. Christian Garms — (Chairman, Non-Governmental 
Organizations Consultative Group) 

Dr. Moses C. Chirambo— Africa 
Dr. Francisco C. Contreras — Latin America 
Dr. P. Siva Reddy— Asia 
Prof. Frank Billson — Pacific 

Treasurer 

Dr. A.T. Jenkyns 

Registrar/Secretary 

Mrs. Virginia Boyce 


341 


342 Appendix C 

REGIONAL CHAIRMEN AND CO-CHAIRMEN 
African Region 

Chairman: Dr. Moses C. Chirambo 
Co-chairman for East: Mr. Samuel K. Tororei 
Co-chairman for West: Dr. Joseph S. Diallo 

American Region 

Chairman for North: Dr. Carl Kupfer 
Co-chairman for North: Mrs. Virginia Boyce 
Co-chairman for North: Mr. John M. Palmer, III 
Chairman for South: Dr. Francisco C. Contreras 
Co-chairman for South: Dr. Fernando Beltranena 
Co-chairman for South: Dr. Newton Kara-Jose 
Co-chairman for South: Dr. Eugenio Maul 

Eastern Mediterranean Region 

Chairman: Sheikh Abdullah M. Al-Ghanim 
Co-chairman: Dr. M. Daud Khan 
Co-chairman: Dr. Ridha Mabrouk 

European Region 

Chairman: Gen. Marcel Chovet 
Co-chairman for West: Dr. Volker Klauss 
Co-chairman for East: Dr. Petja Vassileva 
Co-chairman for East: Prof. Y.F. Maichuk 

South-East Asia Region 

Chairman: Dr. S.R.K. Malik 
Co-chairman: Dr. Rabiul Husain 
Co-chairman: Dr. R.P. Pokhrel 
Co-chairman: Dr. Phanom Sanitprachakorn 

Western Pacific Region 

Chairman: Prof. Frank Billson 
Co-chairman: Dr. Lim Kuang Hui 
Co-chairman: Prof. Kazuichi Konyama 


TAPE Leadership 1990-94 343 


EXECUTIVE BOARD MEMBERS 
Group A 

Appointed by the International Federation of Ophthalmological 
Societies: 


Members 

Alternates 

Dr. Madan Mohan 
Gen. Marcel Chovet 
Dr. Newton Kara -Jose 
Dr. K.Y. Dadzie 
Dr. Ihsan A. Badr 

Dr. Cheng Hu 
Dr. C. Mortimer 
Dr. A.S.M. Lim 
Dr. J. Diallo 
Dr. Kazuichi Konyama 

Group B 

Appointed by the President of the World Blind Union (WBU), sub- 
ject to confirmation by the WBU Executive Board: 

Members 

Alternates 

Sheikh Abdullah M. Al-Ghanim 
Dr. Franz Sonntag 
Sra. Dorina de Gouvea Nowill 
Dr. Rajendra Vyas 
Mr. William Gallagher 

Shahid Ahmed Memon 
Mr. Horst Stolper 
Sra. Molina de Stahl 
Mr. Suresh C. Ahuja 
Mr. David Blyth 

Group C 

National Members: 


Members 

Alternates 


Dr. Hannah B. Faal (Gambia) 
Prof. Adenike Abiose (Nigeria) 
Dr. Delia Durango (Ecuador) 
Dr. F. Beltranena (Guatemala) 
Dr. Sun Bao-chen (China) 

Mrs. Akiko Iwahashi (Japan) 
Dr. S.R.K. Malik (India) 

Dr. Rabiul Husain (Bangladesh) 
Dr. Ahmed Trabelsi (Tunisia) 
Prof. Gordon J. Johnson (UK) 


Prof. Henry S. Adala (Kenya) 
Mr. Samuel K. Tororei (Kenya) 
Dr. Eugenio Maul (Chile) 

Mr. Wilburt Williams (Jamaica) 
Dr. Bage Yaminao (Papua New 
Guinea) 

Prof. Hugh Taylor (Australia) 
Dr. Rajendra Vyas (India) 

Dr. Reggie Seimon (Sri Lanka) 
Dr. Jean-Paul Herbecq (Belgium) 
Dr. Fiisun Sayek (Turkey) 


344 Appendix C 


Group D 

Scientific disciplines other than ophthalmology: 
Member 


Prof. Alfred Sommer 
(Public Health) 

Group E 

A representative from each of the following international and non- 
governmental organizations: 

Christoffel-Blindenmission 

Foresight 

Helen Keller International 
International Eye Foundation 

Norwegian Association of the Blind and Partially Sighted 

Operation Eyesight Universal 

Organisation pour la Prevention de la Cecite 

Project Orbis 

Seva Foundation 

Sight Savers 

Group F 

Individual members by reason of an outstanding contribution 
to international prevention of blindness activities: 

Dr. Joseph Taylor 
Dr. Bjorn Thylefors 
Dr. R.P. Pokhrel 
Prof. G. Venkatas wamy 


Honorary Life Members 

Sir John Wilson 
Prof. Barrie R. Jones 


Appendix D 

Constitution of the International Agency 
for the Prevention of Blindness 


ARTICLE I — Formation and Name 


1. Formation 

An international, non-governmental organization is hereby 
created by organizations concerned internationally with blind- 
ness and with ophthalmology to take over and expand the ac- 
tivities of the International Association for the Prevention of 
Blindness. 

2. Name 

The official name of the Agency shall be “International Agency 
for the Prevention of Blindness” (henceforward in this Constitu- 
tion referred to as “the Agency”). 


ARTICLE II — Commencement 

The Agency comes into operation on the first day of January 1975, 
from which date the International Association for the Prevention 
of Blindness ceases to exist and all the assets and liabilities of the 
said Association are transferred to the Agency. 


ARTICLE III -Headquarters 

The Headquarters of the Agency shall be located at a place 
designated by the Executive Board. 

ARTICLE IV— Purpose and Powers 

1. Purpose 

The purpose of the Agency is to promote the prevention and 


345 


346 Appendix D 


cure of blindness (which expression unless the context other- 
wise indicates, shall include impaired vision) and to preserve 
sight. 

2. Powers 

The Agency may take any action which is conducive to the at- 
tainment of its purpose, including: 

(a) To investigate and make known the causes, extent and con- 
sequences of blindness and to promote, support and en- 
courage all or any measures designed to prevent, cure, reduce 
or remedy diseases, conditions and causes which produce 
blindness. 

(b) To cooperate with the United Nations and its specialized 
agencies, with Governments and with national and inter- 
national organizations concerned in any way with blindness 
and its prevention and to provide opportunities and facilities 
for such cooperation and for the coordination and develop- 
ment of the activities of cooperating organizations. To pro- 
mote and support the establishment, maintenance and 
development of national and regional organizations and 
committees for the prevention and cure of blindness. 

(c) To advance the science, practice and study of ophthalmology, 
to encourage research, and to foster international and 
multidisciplinary cooperation between scientists of different 
disciplines. 

(d) To mobilize and assist in the mobilization of resources 
including the raising of funds, the acceptance of grants, be- 
quests and gifts of all kinds, and the stimulation of govern- 
mental support for national and international action to pre- 
vent and cure blindness. To undertake and execute any trusts 
which may lawfully be undertaken by the Agency and to in- 
vest the funds of the Agency in such investments, securities 
and property as may be approved by the Executive Board. 

(e) To promote the incorporation, registration and recognition 
of the Agency in any country of the world and to promote 
the establishment, maintenance and development of any 
trust, fund or organization whose objects are conducive or 
incidental to the attainment of the purpose of the Agency, 
provided that in any country in which the Agency is 


IAPB Constitution 347 


registered as a charity, the Agency shall not undertake any 
activity which is contrary to such charitable status. 

(f) To collaborate with and support the activities of the World 
Blind Union, the International Federation of Ophthalmolog- 
ical Societies, and to continue the activities of the Interna- 
tional Association for the Prevention of Blindness. 

(g) To engage and remunerate employees, to institute pension 
schemes and other appropriate benefits for employees, ex- 
employees and their dependents and to pay appropriate 
remuneration to any person whose services are required in 
connection with the activities of the Agency provided that 
no officer or member of the Executive Board shall receive 
any salary or remuneration other than reimbursement of ex- 
penses which, in the opinion of the Executive Board, are 
necessarily incurred in connection with the work of the 
Agency. The income and property of the Agency shall be 
applied solely towards the promotion of the purpose of the 
Agency and no portion thereof shall be paid or transferred 
by way of dividend, share, bonus or otherwise by way of 
profit to the members of the Agency apart from the pay- 
ment in good faith of reasonable and proper remuneration 
to any member of the Agency in return for services actually 
rendered. 

(h) To do all such other things as are incidental or conducive 
to the attainment of the Purpose of the Agency. 


ARTICLE V- Members 
1. Categories of Membership 

The Agency may have members in the following categories: 

(a) National Delegates, that is persons nominated for appoint- 
ment as national delegates in accordance with the procedure 
prescribed in Article VI (1) of this Constitution. 

(b) International Delegates, that is persons nominated for ap- 
pointment as international delegates in accordance with the 
procedure prescribed in Article VI (3) of this Constitution. 

(c) Representative Members, that is persons nominated for ap- 
pointment as their representatives by organizations which 
do not have the right to nominate national or international 


348 Appendix D 


delegates but to which the Executive Board or the General 
Assembly has accorded the right to nominate representative 
members. 

(d) Ophthalmologists and Professional Members, that is in- 
dividuals qualified as ophthalmologists or in some science 
or profession recognized by the Executive Board as ap- 
propriate for the purpose of according the status of profes- 
sional membership. 

(e) Honorary Members, that is individuals not exceeding fifty 
in number to whom the General Assembly has accorded the 
status of honorary membership either for life or for a 
stipulated period of years. 

2. Financial Contributions 

The General Assembly shall delegate to the Executive Board 
authority to determine the financial contributions appropriate 
to each category of membership. 


ARTICLE VI -Delegates 

1. National Delegates 

National Delegates may be appointed from any country in which 
there exists a national committee or national organization (or 
any approved grouping of such committees and organizations) 
recognized by the Executive Board as entitled to appoint that 
country’s national delegates. The Executive Board may withhold 
such recognition if it considers that the nominating committee, 
organization or group is insufficiently representative of the 
organizations and interests concerned with the prevention of 
blindness in that country. 

2. Number of National Delegates 

The number of national delegates which may be nominated for 
appointment from any country shall be related to the size of that 
country’s population as revealed in the most recent national cen- 
sus. A country with a population not exceeding 5 million may 
appoint one delegate. A country with a population of more than 
5 million but not exceeding 20 million may appoint 2 delegates. 
A country with a population of more than 20 million but not 


IAPB Constitution 349 


exceeding 50 million may appoint 4 delegates. A country with 
a population of more than 50 million may appoint 6 delegates. 

3. International Delegates 

The Executive Board may authorize an international non- 
governmental organization to nominate a representative for ap- 
pointment as an international delegate. Before according such 
right of nomination, the Executive Board shall be satisfied that 
the organization concerned is international in scope and that 
it promotes, operates or coordinates a substantial program for 
the prevention or cure of blindness. 


ARTICLE VII — Commencement and Termination of Membership 

1. Commencement 

The Executive Board shall appoint a suitable person to act as 
Registrar and such Registrar shall maintain the register of all 
members of the Agency. All applications for membership shall 
be made in writing to the Registrar who, if satisfied that the ap- 
plicant is qualified for membership in accordance with the pro- 
visions of Article V of this Constitution and that any appropriate 
financial contributions have been paid, shall enter the applicant’s 
name in the register of members and the applicant shall there- 
upon assume the rights appropriate to the category of member- 
ship. Any person or organization whose application is refused 
by the Registrar or whose application is not proceeded with 
within three months, may appeal to the Executive Board or to 
a Committee of the Board authorized to consider such appeals 
and the decision of the Board or of such Committee shall be 
final. 

2. Termination 

A member’s name shall be withdrawn from the register and 
membership shall cease if: 

(a) Membership is terminated by the organization or commit- 
tee which nominated the member a delegate or representative 
member. 

(b) Membership is terminated by resolution of the Executive 
Board. 


350 Appendix D 


3. The Register 

The Register of Members, or a true copy thereof, shall be kept 
at the Headquarters and shall be open to inspection during nor- 
mal office hours by any member of the Agency. 


ARTICLE VIII -The General Assembly 

1. The first General Assembly shall be convened by the President 
not later than three years from the date on which the Agency 
comes into operation. Subsequent Assemblies shall be held at 
intervals not exceeding four years and at a time and place deter- 
mined by the General Assembly or the Executive Board. The 
President, by giving two months’ written notice to all members, 
may convene an Extraordinary General Assembly and shall con- 
vene such an Assembly if he is requested to do so by a majority 
of the members of the Executive Board or by a majority of the 
national and international delegates. General Assemblies shall, 
so far as possible, be held at a time and place likely to be conve- 
nient to a majority of the members having regard to the timing 
of other international conferences of ophthalmologists or of 
blind welfare workers. 

2. Function 

The General Assembly shall be the governing body of the Agency 
and its decisions shall determine the general policies by which 
the Agency shall seek to achieve its purpose. The General 
Assembly shall elect the officers and the Executive Board in 
accordance with the procedure prescribed in Article X and XI 
of this Constitution. It shall review the work of the Executive 
Board, approve the general report, accounts and budget of the 
Agency, and shall regulate the Agency’s relationship with other 
organizations. 

3. Resolutions 

The General Assembly shall have the power to adopt special and 
general resolutions. A special resolution of the General Assembly 
is a resolution which concerns: 

(a) the amendment of the Constitution; 

(b) the number of members in each group of the Executive 
Board as prescribed in Article XI of this Constitution and 


I APB Constitution 351 


the election or appointment of members in Groups A, B, 
C, and E of the Executive Board; 

(c) approval of the financial estimates of the Agency; 

(d) the dissolution of the Agency. 

A general resolution is a resolution which is concerned with any 
other business of the General Assembly. In the event of disagree- 
ment whether a resolution is special or general, the decision of 
the President or, in his absence, of the officer presiding as Chair- 
man of the Assembly, shall be final. Except with the approval 
of the Executive Board, no special resolution shall be proposed 
in the General Assembly unless it has previously been submitted 
in writing to the President at least eight weeks before the com- 
mencement of the General Assembly. 


ARTICLE IX— Votes in the General Assembly 

1. Votes on General Resolutions 

Every registered member of the Agency may attend and par- 
ticipate in the business of the General Assembly and may exer- 
cise one vote on any general resolution. 

2. Votes on Special Resolutions 

Only national delegates, international delegates and members 
of the Executive Board may vote on a special resolution as de- 
fined in Article VIII (3) of this Constitution. 

3. Limitation 

On any resolution not more than 15 percent of the votes shall 
be cast by members who are citizens of the same country. If in 
any General Assembly more than 15 percent of the members with 
voting rights are citizens of the same country, these members 
shall decide between themselves on the limitation of their voting 
rights in accordance with this Clause and should they fail to agree, 
the matter shall be decided by lot. 

4. Quorum 

At any General Assembly, 40 members shall constitute a quorum 
for the purpose of considering a general resolution and 30 mem- 
bers with voting rights on a special resolution shall constitute 
a quorum for the purpose of considering a special resolution. 


352 Appendix D 


5. All resolutions at a General Assembly shall be decided by a 
majority of the votes cast except for resolutions to amend the 
Constitution or dissolve the Agency, which shall be decided in 
accordance with the procedure prescribed in Article XIII and 
Article XIV of this Constitution. Voting may be viva voce, by 
show of hands or by ballot which may be secret if so decided 
by the President or, in his absence, by the officer presiding as 
Chairman of the Assembly. Unless otherwise decided by the 
General Assembly, the election of an officer of the Agency shall 
be by secret ballot. Between meetings of the General Assembly 
questions which, in the view of the Executive Board lie outside 
the powers committed to that Board, may be decided by postal 
ballot of all members qualified to vote on the question at issue. 

6. Proxies 

A national delegate who is unable to attend a session of the 
General Assembly may authorize another member of his national 
delegation to exercise a proxy vote on his behalf. Written notice 
of such proxy must be given to the President before the com- 
mencement of the session of the General Assembly at which such 
proxy vote will be exercised. No delegate shall exercise more than 
two proxy votes. 

7. In the event of an equality of votes on any resolution the Presi- 
dent or, in his absence, the officer presiding as Chairman of the 
Assembly, may exercise a second or casting vote. 


ARTICLE X- Officers 

1. The Officers of the Agency shall be: President, one or more Vice 
Presidents, Treasurer, and such other officers as may from time 
to time be appointed by special resolution of the General 
Assembly. If more than one Vice President is appointed, one 
of them shall be designated as the Senior Vice President. 

2. Officers shall be elected by general resolution of the General 
Assembly from amongst the members elected or appointed at 
that Assembly as members of the Executive Board. The officers 
of the Agency shall hold office until the conclusion of the next 


I APB Constitution 353 


General Assembly when they shall retire from office but, sub- 
ject to the provisions of Clause 3 of this Article with regard to 
the period of office of the President, shall be eligible for 
re-election. 

3. The President, in cooperation with the Officers, shall give leader- 
ship in the activities of the Agency and in the formulation of 
its policy. The President shall have the right to preside at all 
meetings of the General Assembly and of the Executive Board. 
No person shall hold the office of President for a consecutive 
period exceeding eight years but, should this period elapse be- 
tween meetings of the General Assembly, the President may con- 
tinue in office on a temporary basis until the conclusion of the 
next General Assembly at which the new President shall be 
elected. 

4. The Vice President, or should there be more than one Vice Presi- 
dent, the Senior Vice President, shall act as assistant to the Presi- 
dent and, in the President’s absence, shall preside at meetings 
of the General Assembly and of the Executive Board. In the event 
of the incapacity, resignation or death of the President, the Senior 
Vice President shall assume the duties of the President pending 
the election of a new President by the General Assembly. If the 
President for the time being is not a qualified ophthalmologist, 
the Senior Vice President or other qualified officer designated 
by the Executive Board, shall act as the Agency’s representative 
on the International Council of Ophthalmology. 

5. The Treasurer and President shall undertake the duties ap- 
propriate to their respective offices and such additional duties 
as may be specified by the Executive Board or the President. In 
the event of disagreement about the duties of the respective Of- 
ficers, the decision of the President shall be final. 

6. The Officers, immediate past president, and Regional Chairmen 
collectively shall act, under the chairmanship of the President, 
as an Executive Committee of the Executive Board with power, 
between meetings of the Board, to make decisions necessary for 
the continuation and advancement of the work of the Agency 
and to undertake such additional duties as may be assigned to 
them by the Executive Board. Four ad hoc non-voting members 


354 Appendix D 


may be selected by the President from the Executive Board to 
serve at the discretion of the President. 


ARTICLE XI — Executive Board 

1. Each General Assembly shall elect an Executive Board whose 
members shall serve until the conclusion of the next General 
Assembly when they shall retire from office but be eligible for 
re-election. 

2. The Executive Board shall consist of the following groups of 
members: 

Group A. Members appointed by special resolution on the 
nomination of the International Council of Ophthalmology to 
represent organizations concerned with ophthalmology and with 
the prevention of blindness. 

Group B. Members appointed by special resolution on the 
nomination of the World Blind Union to represent organizations 
for and of the blind. 

Group C. Members elected by special resolution to represent the 
national delegates appointed in accordance with the provisions 
of Article VI of this Constitution. 

Group D. Members elected by general resolution to represent 
scientific disciplines other than ophthalmology. 

Group E. Members appointed by special resolution on the 
nomination by the Partnership Committee of international non- 
governmental organizations to represent those organizations 
whose activities contribute to the attainment of the purpose of 
the Agency. 

Group F. Members elected by general resolution in recognition 
of the individual contribution which they can make to the work 
of the Agency. 

3. Until otherwise determined by special resolution of the General 
Assembly, the maximum number of members in each of the 
Groups prescribed in Clause 2 of this Article, shall be: 

Group A: Five Group D: Four 

Group B: Five Group E: Ten 

Group C: Twelve Group F: Four 


I APB Constitution 355 


4. Alternates 

For each member of the Executive Board, an alternate may be 
appointed who, on behalf of and at the request of the member, 
may attend and vote at any meeting of the Board from which 
the member is absent. Each alternate shall be appointed by the 
same procedure as that described in Clause 2 of this Article for 
the appointment or election of the member whose alternate he 
is. No alternate shall perform any of the duties of an Officer. 

5. Vacancies 

Between General Assemblies, any member of the Executive Board 
who vacates office shall be succeeded by the alternate and the 
Executive Board shall thereupon appoint another suitable per- 
son to serve as alternate. In the event of the incapacity, resigna- 
tion or death of an Officer other than the President, the Ex- 
ecutive Board may appoint one of its members to perform the 
duties of the vacant office until the next meeting of the General 
Assembly. 


ARTICLE XII — Powers of the Executive Board 

1. The Executive Board shall be responsible for interpreting the deci- 
sions and policies adopted by the General Assembly. It shall ad- 
minister, manage and control the affairs, finances and property 
of the Agency and in so doing shall be authorized to take any 
action not specifically reserved for the General Assembly. It shall 
supervise the activity of the Officers and employees of the Agency 
and shall have the right at all times to receive reports on their 
activity. 

2. The Executive Board shall decide on the time and place of its 
meetings which shall be held at least once every two years. At 
any meeting of the Board, a quorum shall consist of half the 
members for the time being of the Board or eight members, 
whichever number is least. An alternate attending a meeting on 
behalf of a member, shall count as a member for the purpose 
of the quorum. 

3. The Executive Board may decide on any matter within its com- 
petence by: 


356 Appendix D 


(a) The agreement of a majority of the members present at a 
meeting at which there is a quorum as defined in Clause 
2 of this Article. 

(b) The agreement of a majority of the members voting in a 
postal ballot which has been circulated to all members at 
least six weeks before the votes are counted and in which 
votes are recorded by not fewer than half the members of 
the Executive Board or by eight members, whichever is least. 

In the event of an equality of votes, the President or 
officer presiding as Chairman of the Executive Board may 
have a second or casting vote. 

4. Committees 

The Executive Board may appoint Committees for any purpose 
with such terms of reference and duties as it may decide. Such 
Committees shall consist of members of the Agency but non- 
members may be co-opted in a consultative or advisory capacity. 

5. Financial Control 

It shall be the duty of the Executive Board to ensure the 
maintenance of an efficient system of accountancy and finan- 
cial control and at all times to cause expenditure to be regulated 
within the income and resources of the Agency. The accounts 
and balance sheet of the Agency shall be audited annually by 
a professionally qualified auditor and copies of the accounts and 
balance sheet together with a report on the activities of the 
Agency, shall be made available annually to all registered mem- 
bers of the Agency and to any authorities entitled to receive such 
accounts and reports. 

6. Nominations 

At the time of the General Assembly, the Executive Board shall 
be entitled to propose, for the consideration of the Assembly 
or of any nominations committee appointed by the Assembly, 
the names of persons it considers suitable for nomination as of- 
ficers or as members of the Executive Board. These nominations 
shall in no way limit the freedom of choice of the Assembly. 


I APB Constitution 357 


ARTICLE XIII — Constitutional Amendments 

1. This Constitution may be amended: 

(a) By a special resolution of the General Assembly (as defined 
in Article VIII (3) of this Constitution), adopted by a ma- 
jority of not less than two thirds of the members present 
and voting on the resolution. 

(b) With the consent of the Executive Board by a postal ballot 
of all members entitled to vote on a special resolution pro- 
vided that not less than two thirds of the votes cast are in 
favor of the proposed amendment. 

2. A Constitutional amendment may be proposed by the Executive 
Board or by not less than five members of the Agency. Any 
amendment proposed for consideration by the General Assembly 
shall be submitted in writing to the Secretary-General at least 
three months before the commencement of the General Assembly 
at which the amendment is to be considered. 


ARTICLE XIV- Dissolution 

The dissolution of the Agency shall require a special resolution of 
the General Assembly proposed by the Executive Board and adopted 
by a majority of not less than two thirds of the members present 
and voting on the resolution. In the event of bankruptcy and sub- 
ject to any laws applicable to the Agency, the personal liability of 
any member of the Agency shall be limited to a maximum of $10. 
On the dissolution of the Agency, any remaining assets shall be 
disposed of in accordance with the recognized legal procedure of 
the country in which such assets are owned. 































































Appendix E 

IAPB Membership Criteria 


The following are membership criteria for national and international 

organizations that wish to join the International Agency for the 

Prevention of Blindness. Such an organization must: 

1. Be a formally organized national or international non-govern- 
mental organization operating with a constitution and by-laws 
and governed by a board of directors with representation from 
the professions related to prevention of blindness and nonprofes- 
sional representatives from corporations, banking, the legal field, 
fraternal organizations, women’s groups, etc. 

2. Have a corps of voting members to elect the board of directors. 

3. Have appropriate financial management and controls and an 
annual budget related to program expenditures. 

4. Operate a program with the goal of preventing blindness among 
all ages and in all areas of service through research in causes 
of blindness and impaired vision, public and professional educa- 
tion and community services, i.e., vision testing and correction, 
cataract treatment, glaucoma detection, eye safety, control of 
diseases such as onchocerciasis, ophthalmic neonatorum, and 
general disease infections. 

5. Employ a paid staff qualified to plan and execute a program. 

6. Produce an annual report and financial statement. 

7. Serve as an advocate of the prevention of blindness activities 
of government agencies. 

8. Accept responsibility for providing financial support to IAPB. 


359 


360 Appendix E 

Information to be supplied on application form: 

Name of Organization 

Address 

Date founded 

Names and addresses of officers 
Names and addresses of governing board 
Number of voting members 


The following must also be submitted with the application: 

1. Copy of Constitution and by-laws, 

2. Copy of financial statement and budget, 

3. List of sources of funds (government and non-government) and 
amount by source, 

4. Brief description of program, and 

5. Annual report. 


Send this information to: 
Mr. Alan W. Johns 
IAPB Secretariat 
P. O. Box 191 
Haywards Heath 
West Sussex RH16 4YF 
United Kingdom 


Appendix F 


A Brief Overview of the Global Program 
for the Prevention of Blindness 

by Carl Kupfer, M.D. 

THE WORLDWIDE PROBLEM OF AVOIDABLE BLINDNESS 

Although excellent ophthalmic procedures and eye-care delivery 
systems are accessible in the developed world, adequate health care 
is not readily available in all parts of the developing world. This 
widening gap in visual health between developed and developing 
nations threatens to have ominous consequences. If present trends 
continue, the number of blind people — today estimated at 27-35 
million — will more than quadruple during the next 40 years* Trag- 
ically, as many as 90 percent of these blind people will live in develop- 
ing countries. 

The difficulty of adequate eye-care delivery can be exemplified 
by experiences in India and China. Over the past 10 years in India, 
the number of annual cataract operations has grown from 0.5 to 
1.2 million. However, there are 3.8 million new cases each year. 
Therefore, 3 times as many cataract operations are needed each year 
in India just to keep up with the new cases, whilst no progress is 
being made to reduce the backlog of some 7 million blind. Surveys 
carried out in China in 1984-85, have estimated that there are 
5 million blind people, of whom perhaps 3 million have unoperated 
cataracts. In response to these estimates, a national program was 
formulated in 1986. Since then, more than 20 provinces have iden- 
tified pilot counties in which to launch programs of primary eye 


*The definition of blindness used here, unless stated otherwise, is corrected visual 
acuity less than 3/60 (20/400) in the better eye, which is the internationally- 
accepted definition of blindness and indicates the inability to count fingers at 
a distance of three meters or to walk around unguided. Severe visual impair- 
ment is defined as visual acuity in the better eye equal to or less than 6/60 
(20/200) to 3/60. 


361 


362 Appendix F 


care that include the goal of providing mass intervention for cataract. 
Although at the start of this Chinese national program there were 
only 50,000 cataract operations annually, the Ministry of Health 
has set the goal of 500,000 operations per year to be reached by 
1992. In addition, the training of ophthalmologists has been given 
very high priority. 

Designing and funding delivery systems to handle such large 
increases in places like India and China would challenge any 
developed country, but in the developing world the needed response 
will be even greater. The population 55 years of age and over in 
the developing world will increase by almost 500 percent in the next 
40 years, with a concomitant increase in all of the blinding condi- 
tions related to aging. 

This large-scale disablement caused by blindness is not only a 
costly obstacle to economic development, it is a catastrophic loss 
of human potential in the very parts of the world most desperately 
in need of a healthy work force. In addition, because more than 
80 percent of all cases of blindness can be considered avoidable — 
that is, they could have been prevented or could be cured using 
available and locally appropriate technology— such deprivation is 
a truly needless denial of a basic human right for millions and 
millions of people. 

The problem in most developing countries lies not in the abil- 
ity of ophthalmic workers to diagnose properly, but rather in the 
inability of national health-care systems to provide appropriate 
therapy. Effective programs for preventing and curing blindness in 
these countries will require the development of an infrastructure 
to deliver mass treatment at low cost. The appropriate technology 
for such situations will depend upon what is acceptable within the 
existing culture. If the therapy is rejected or if it is too complicated 
or expensive, it could postpone or preclude the implementation of 
less elaborate but more effective procedures. 


ACHIEVEMENTS OF THE GLOBAL PROGRAM 
FOR THE PREVENTION OF BLINDNESS 
DURING THE PAST 10 YEARS 

The achievements of the global program for the prevention of blind- 
ness have depended upon the creation of the World Health Organiza- 
tion (WHO) Prevention of Blindness Program, the establishment 


A Brief Overview 363 


of national prevention of blindness committees, and the strengthen- 
ing and cooperation of the international non-governmental organiza- 
tions (NGOs) involved in prevention of blindness programs. The 
overall coordination of these activities has been facilitated by the 
International Agency for the Prevention of Blindness (IAPB). 

The IAPB is an international non-governmental agency founded 
by Sir John Wilson in 1975 to lead a cooperative universal offen- 
sive to reduce drastically the world’s avoidable blindness. The 
establishment of this global prevention of blindness program has 
effectively enabled the participating organizations to speak with one 
voice to the world regarding prevention of blindness issues since 
1975. The IAPB does not raise funds, but rather depends upon dues 
from its constituent NGOs to support its modest annual budget 
of about $100,000. 

Because the WHO Program cannot help a nation establish a 
blindness prevention program until it has been officially invited to 
do so by that nation’s government, the IAPB promotes awareness 
of the existence of the WHO’s Program and encourages the develop- 
ment of national prevention of blindness committees in countries 
where they do not already exist. Such a committee can then work 
with that nation’s Ministry of Health to prepare the invitation and 
subsequently work with WHO to appraise the situation and design 
an appropriate program. The NGOs are often able to help fund 
the projects identified by the WHO team. 

The prevention of blindness community’s perception of the im- 
portance of coordinating its activities was heightened at the World 
Health Assembly in Geneva in 1985. At that meeting the major 
technical discussions focused on the need for increased collabora- 
tion between the WHO and NGOs. The IAPB exhibit and presen- 
tation at that Assembly received considerable attention from the 
delegates because we demonstrated how well WHO, individual 
NGOs, and national committees had interacted in designing and 
operating prevention of blindness programs in Latin America, Asia, 
and Africa. 

The principal goal of IAPB is to control the four major diseases 
that cause more than two thirds of all blindness in the developing 
world: cataract, trachoma, onchocerciasis, and xerophthalmia. Over 
the past decade, this consortium of NGOs and national commit- 
tees in over 60 countries has directed efforts toward mobilizing 
resources, increasing public awareness, supporting sight-conservation 


364 Appendix F 


programs, and implementing WHO health-care strategies aimed at 
arresting the ravages of these diseases. 

Other major coordinative activities of the IAPB include the 
General Assemblies held every four years. At these Assemblies over 
400 major players in the prevention of blindness field— often from 
as many as 60 countries worldwide — meet, make formal presenta- 
tions describing successful programs, compare notes regarding 
obstacles that must be overcome, and prepare revised strategies for 
their next four years of effort. 

The IAPB is represented at regional WHO meetings and helps 
encourage WHO prevention of blindness activities in the develop- 
ing world. The IAPB also holds regional IAPB meetings periodically 
(its regional structure matches that of WHO). The IAPB occasion- 
ally co-sponsors workshops to develop priority programs. One 
important recent workshop helped establish the concept of Cataract- 
Free Zones and another applied the principles of operations research 
to overcoming barriers to cataract surgery. A third has resulted in 
a clinical trial to be conducted in two developing countries to assess 
the cost-effectiveness, efficacy, and safety of cataract surgery using 
the intraocular lenses as compared with using aphakic spectacles 
to provide optical correction after removal of the lens. The IAPB, 
in conjunction with the National Eye Institute of the National 
Institutes of Health in Bethesda, Maryland, also coordinates sym- 
posia and seminars on prevention of blindness topics, often in con- 
junction with major international meetings such as those of the 
International Council of Ophthalmology. 

The IAPB also functions as a clearing house, facilitating the 
dissemination of information among the organizations and com- 
mittees concerned with prevention of blindness through its publica- 
tion of the IAPB News , which is mailed twice a year to 4,500 eye- 
care professionals in 148 countries. 

An encouraging trend fostered by IAPB has been that preven- 
tion of blindness programs have become increasingly innovative. 
We are continually finding new forms of intervention that are low 
in cost, safe, and highly effective. As an example, I would point 
to the evolution of the programs to prevent xerophthalmia by in- 
creasing vitamin A intake. Initially, all these programs were based 
on supplementation by means of vitamin A in capsules or solu- 
tions, and that remains a feature of most of these programs. But 
new approaches have also emerged. One of these is fortification 


A Brief Overview 365 


of locally consumed foods, which makes it possible to achieve rapid 
and widespread distribution of vitamin A. 

Another innovative strategy, which may be even more promis- 
ing in the long run, is the educational approach that teaches mothers 
to use in the family diet naturally occurring sources of vitamin A 
from the local environment. Where education succeeds, people will 
be safe from vitamin A deficiency for generations. That is an enor- 
mous impact, and it can be realized through a program that in the 
long run is relatively low in cost. 

In addition, our awareness of the problem of cataract has in- 
creased over the past decade. In 1975 we were alert to the dangers 
posed by infectious diseases such as trachoma and onchocerciasis, 
but we were less aware of cataract as a cause of avoidable blindness. 
Now, as a result of surveys and careful re-examination of our patient 
populations, we now know that cataract is the major cause of 
avoidable blindness in almost all regions of the developing world. 
Therefore, because cataract is responsible for over one half of 
the world’s avoidable blindness, we must adjust our priorities 
accordingly. 

Also, because of all the advances I have mentioned and our new 
knowledge about the causes and distribution of blindness, we are 
better equipped than ever to demonstrate the value of programs for 
the prevention of blindness. We can document the reduction in 
prevalence of blindness and the concomitant cost-effectiveness of 
these efforts. This gives us an even better chance of attracting the 
resources needed to support large-scale programs to combat 
blindness. 


WHO PROGRAM FOR THE PREVENTION OF BLINDNESS 

Since 1978, the worldwide focal point for development of preven- 
tion of blindness programs has been the WHO Program for the 
Prevention of Blindness, which for the past decade has been very 
capably directed by Dr. Bjorn Thylefors. 

The Program has undertaken the development of an agenda for 
the promotion and coordination of national programs for the 
prevention of blindness. In fulfilling this responsibility, the Pro- 
gram includes the following: 

1. Overall planning and coordination for the implementation 
and evaluation of national programs; 


366 Appendix F 


2. Identification of needs and stimulation of contributions; 

3. Coordination of activities relating to the prevention of blind- 
ness undertaken by other international, governmental, and 
NGOs and bilateral technical-assistance programs; 

4. Stimulation and coordination of research required to meet 
the needs of national programs; 

5. Collection and dissemination of relevant information; and 

6. Promotion of training of required personnel at all levels. 

Typically, WHO will conduct a prevalence survey to establish 
the extent of the problem of blindness in a given country. Recent 
WHO prevalence surveys have been conducted in the People’s 
Republic of the Congo, the Republic of Turkey, and Nepal. Such 
a survey will provide an objective assessment of the major needs 
and opportunities that must be addressed in planning that coun- 
try’s prevention of blindness program. Using the information con- 
tained in such a research base, individual international NGOs will 
be able to judge if they have the right mix of programmatic interest, 
available funds, and managerial talent to undertake a prevention 
of blindness project in that country. 

For example, after the prevalence survey was completed in Nepal, 
the Nepalese government, WHO, and the local prevention of blind- 
ness organization Nepal Netra Jyoti Sangh were joined by three 
charitable organizations from within Nepal and ten international 
NGOs who divided the country into manageable sections. Within 
six years the number of patients receiving outpatient examinations 
and treatment annually increased from 2,700 to 265,608, and the 
number undergoing cataract surgery annually increased from less 
than 500 to 14,833. 

Mechanisms for implementation of the WHO Program include 
the establishment of a network of 14 WHO Collaborating Centers 
worldwide for the Prevention of Blindness and consultation with 
various program advisory groups and with members of relevant 
WHO expert panels. Several of the WHO Collaborating Centers 
have developed courses in community ophthalmology and have 
sponsored research projects dealing with delivery of eye care using 
appropriate technology. 

Although the primary role of the WHO is that of promoter or 
catalyst of technical cooperation and collaboration among develop- 
ing countries, there are several additional ways in which WHO may 


A Brief Overview 367 


provide other critical inputs, depending upon circumstances and 
subject to requests from national authorities. 

The following are examples of such activities: 

1. Assessment of the nature and extent of the problem (through 
national prevalence surveys); 

2. Formulation of national or regional plans, programs, and 
projects (in 70 countries in 1991); 

3. Collection, elaboration, and distribution of relevant data 
(through the global data bank); 

4. Organization and management of training activities such as 
seminars, meetings, and training courses — including the 
preparation and provision of teaching aids (for example vita- 
min A deficiency primary eye-care posters); 

5. Procurement of essential supplies and equipment (for ex- 
ample cataract instruments for Laos and Vietnam); and 

6. Advisory services by staff members or by short-term consul- 
tants, and possibly by personnel assigned for longer periods. 

It is particularly heartening to see how much the WHO Prevention 
of Blindness Program has grown. When it was established in 1978, 
the Program had no separate budget. In 1980, when it was first 
assigned funds of its own by WHO, the Program was given $1.3 
million for two years of operations. However, just a few years later, 
for the 1984-85 biennium, the budget had almost doubled to $2.3 
million per year. For the current biennium of 1990-91 the regular 
budget for the Program is over $2.4 million, plus extra-budgetary 
funds of $1.6 million. Such extra-budgetary funding has come from 
a variety of sources, including the Japan Shipbuilding Industry 
Foundation, the Arab Gulf Fund for the United Nations Develop- 
ment Organization (also known as AGFUND), and the United Na- 
tions Development Program (UNDP). 

The global program has drawn attention to the issue of blind- 
ness prevention, and it has stimulated more action in the field, both 
in professional-scientific contexts and in administrative-political cir- 
cumstances. Much of this promotional work has been done in close 
collaboration with WHO and IAPB and its member NGOs. 

Another major achievement of the global program has been the 
successful development of a primary health-care approach to the 
prevention of blindness. The concept of primary eye care as a 


368 Appendix F 


cornerstone of primary health care has become not only impor- 
tant in the development of national programs but crucial for the 
NGOs’ support to those programs. Although primary eye care is 
today a universally accepted strategy for blindness prevention, this 
concept would have been very difficult to achieve without the WHO 
Program and the input from IAPB and the other NGOs. 

The need for technical guidance within national programs that 
are attempting intervention schemes against major causes of blind- 
ness has resulted in increased program documentation. Particularly 
noteworthy are strategies for national cataract reduction programs, 
WHO publications in areas such as trachoma and xerophthalmia 
control, control of conjunctivitis in the newborn, and the provi- 
sion of spectacles at low cost. In addition, there have been impor- 
tant developments in writing and distributing training materials in 
eye care. 

Using population-based surveys, the global program has also 
developed a uniform simple methodology for assessing avoidable 
blindness. Using today’s commonly accepted international defini- 
tions of blindness and visual impairment, this methodology has 
greatly improved the availability of epidemiologically sound and 
comparable data on blindness and its causes from various coun- 
tries. Much of this work has been supported by the National Eye 
Institute, which has funded field surveys in several countries to test 
examination procedures and record keeping. 

A global data bank on blindness was established within the 
WHO Program from its outset. This data bank is continuously be- 
ing revised and updated; it contains at present over 150 references 
from 90 countries. The first compilation of all available data was 
the subject of a Task Force in 1978, which produced a report 
estimating the number of blind in the world to be about 28 million. 
A second comprehensive compilation and analysis of data was car- 
ried out in 1987 and provided an estimate of 27 to 35 million blind 
persons worldwide. 

In the field of applied research, the WHO Program has exten- 
sively used its network of Collaborating Centers. In spite of initially 
very limited financial resources, a wide range of research tasks has 
been completed, covering specific aspects of disease control or train- 
ing of personnel. Again, the National Eye Institute has provided 
much valuable support to the research component of the Program 
over these years. 

Another important activity of some of the WHO Collaborating 


A Brief Overview 369 


Centers has been the establishment of training courses in public 
health aspects of ophthalmology. These courses are creating a cadre 
of national program managers who will be of great importance in 
the implementation of national programs. 


Non-governmental Organizations generate the resources 
to support prevention of blindness programs 

The major NGOs include Christoffel-Blindenmission (Germany), 
Foresight (Australia), Helen Keller International, the International 
Eye Foundation, and Seva (USA), Operation Eyesight Universal 
(Canada), Sight Savers or the Royal Commonwealth Society for the 
Blind (UK), and the Organisation pour la Prevention de la Cecite 
(France). Since the establishment of the WHO Prevention of Blind- 
ness Program, these NGOs in the field who have been invited to 
send observers to the biennial meetings of the 12-member WHO 
Prevention of Blindness Program Advisory Group, which is ap- 
pointed by the WHO Director-General. However, to facilitate fur- 
ther development and coordination of activities, in 1986 the WHO 
established the Consultative Group of NGOs to the WHO Preven- 
tion of Blindness Program. 

The purpose of the Consultative Group, which meets in the years 
when the Program Advisory Group does not meet, is to provide 
an opportunity for communication between WHO and interested 
NGOs regarding particular projects or needs in selected countries 
where the WHO Program does not have the required resources to 
intervene but where NGOs have good working channels. Through 
such cooperation with the WHO Program, the NGOs have provided 
valuable help to WHO, including support to staff in the WHO 
regions, funding for joint meetings, and promotion of selected na- 
tional blindness programs. In return, the WHO has facilitated where 
possible the introduction of NGOs to Ministers of Health in coun- 
tries receptive to the development of programs. 

Another NGO committee is called the Partnership. The purpose 
of this group, which meets periodically, is to coordinate activities 
between NGOs that are working in the same countries or regions. 

Concomitant with the substantial increases in WHO funding, 
there has been a parallel growth in the resources of the NGOs that 
are such an important part of blindness prevention and of the 
IAPB. In 1991 the major NGOs in the field plan to expend about 


370 Appendix F 


$60 million on blindness prevention and related activities. The com- 
parable figure for 1975 was only $6 million. 

This growth means that these organizations now command the 
resources to support sizeable programs that have a highly noticeable 
impact. The extensive cataract surgery programs throughout Asia 
and Africa sponsored by Sight Savers, Christoffel-Blindenmission, 
Operation Eyesight Universal, and the Seva Foundation constitute 
one example. The massive vitamin A supplementation programs 
begun by Helen Keller International are another. The programs for 
training allied health personnel sponsored by the International Eye 
Foundation are a third. There is every reason to believe that the 
growth in resources that makes such programs possible will con- 
tinue in the future. 


National Programs for the Prevention of Blindness 

The global program for the prevention of blindness has been very 
successful in developing national programs for the prevention of 
blindness. Over 60 countries have collaborated with WHO and IAPB 
in the preliminary assessment of blindness and its causes, the prep- 
aration of national plans, and the implementation or evaluation 
of programs. Some of these national programs were in existence 
well before the creation of the WHO Program and the IAPB, but 
at that time mainly as specific trachoma control programs. These 
programs have been gradually expanded to incorporate other causes 
of visual loss and have been used to establish broad-based national 
prevention of blindness programs and to integrate them within the 
framework of each country’s primary health care. 


ACHIEVABLE AND SUSTAINABLE 
PROGRAM TARGETS TO THE YEAR 2000 

To mobilize the resources needed to prevent needless loss of 
vision — 80 percent of the blindness in the world is avoidable — the 
prevention of blindness community must implement a global 
strategy aimed at: 1) increasing public and governmental awareness 
of the extent of the problem, 2) encouraging decision-makers to 
allocate funds and staff support for relevant programs, 3) develop- 
ing effective programs in countries that currently lack them, and 
4) increasing the effectiveness of programs already in existence. 


A Brief Overview 371 


If the global program for the prevention of blindness is to make 
progress in achieving these objectives by the year 2000, it must secure 
broader support for its activities immediately. This requires further 
improving the flow of information among the many individuals and 
groups concerned with blindness prevention and to facilitate addi- 
tional cooperation between WHO, UNICEF, UNDP, bilateral aid 
agencies, the major NGOs involved in international blindness 
prevention, and the national committees of the IAPB. The IAPB, 
by serving as a clearinghouse for ideas and information on success- 
ful approaches to blindness prevention, and by helping to match 
available resources with promising programs that require assistance, 
can do much to ensure efficient use of the resources now available 
for blindness prevention. 

Strengthening the national committees, both in their dealings 
with international organizations and in their home countries, is 
another priority for the next decade. This can be accomplished in 
three ways. First, contact between these national committees and 
the IAPB leadership should be increased. Second, a greater effort 
should be made to acquaint national committees with the interna- 
tional NGOs that may be able to assist them in meeting their 
blindness prevention goals. And third, it is necessary to improve 
communication among the various national committees and to 
encourage the exchange of ideas and experiences among them. 

The international prevention of blindness program must broaden 
its base of support and develop a strong grass-roots constituency 
if it is to continue to make progress in the years to come. The new 
SightFirst Program of Lions Clubs International promises to be an 
example of how to harness such broad-based support. Because there 
are over 1.3 million Lions in 171 countries, this new program is likely 
to become an important resource in the international battle against 
preventable and curable blindness. To broaden our international base 
of support eye-care professionals, the general public, health-related 
associations, government officials, and charitable organizations 
around the world must become acquainted with our prevention of 
blindness efforts and our aims. In addition, they must be persuaded 
to help. Ophthalmological societies have already been identified as 
a key target of any effort to increase grass-roots support. With 
stronger support from the world’s ophthalmologists, the program 
will be in a better position to approach governmental decision- 
makers and NGOs who can provide invaluable support for the 
international campaign against blinding eye diseases. Ophthalmol- 


372 Appendix F 


ogists can also be highly persuasive in bringing the problems of 
world blindness to the attention of the general public in their own 
countries, thus generating additional support. 

In addition to the above, a greater effort must be made to iden- 
tify prevention of blindness programs that are particularly worthy 
of increased support, so that we can present persuasive arguments 
to decision-makers, particularly those in NGOs who arrange fun- 
ding. To accomplish this, we must have more reliable information 
on the programs now in existence and on the needs that future pro- 
grams must address. 

There is no doubt that the growing problem of cataract will need 
to receive priority attention in most countries. It will require great 
effort to make cataract surgery available and to provide appropriate 
optical correction to all those in need of it. There is already a large 
backlog of unoperated cataract in many developing countries. The 
elimination of such a backlog, and keeping pace with the ever- 
increasing demand for surgery, will pose many problems for the 
eye-care systems in countries with meager resources. 

To address problems such as this enormous backlog of cataract 
cases, relevant management courses will be instituted in English at 
the Aravind Eye Hospital in Madurai, India, and in French at the 
Institut d’Ophtalmologie tropicale de l’Afrique, the WHO Col- 
laborating Centre in Bamako, Mali. The latter institute will also 
conduct a study in ways of improving cataract outpatient surgery 
in Africa. 

In addition, there will be an ophthalmic manpower training 
center developed in Malawi and the National Eye Institute, as a 
WHO Collaborating Center, with the IAPB will offer a course in 
operations research for managers of eye hospitals, clinics, and 
research facilities in the developing world. 


LESSONS TO BE LEARNED FROM THE 
PREVENTION OF BLINDNESS PROGRAM 

The limiting factor in the prevention of blindness program is not 
simply money but the availability of well-organized and well- 
managed projects that have a high probability of success. Such proj- 
ects will attract funding, but there remains the challenge of having 
available: 1) the necessary leadership in prevention of blindness, 


A Brief Overview 373 

2) the experience in managing such programs, and 3) the ability 
to evaluate the outcome. 

Leadership refers to making the right choices, such as choosing 
the right programmatic direction and the right priority judgements. 
However, after the right choice has been made, it is the manager 
of the program who must see to it that the right choices are im- 
plemented efficiently. Whereas leadership involves aligning people 
toward a common vision and stimulating their desire to achieve it, 
management is concerned with the details of project staffing, 
mobilizing necessary resources, and attending to the many details 
necessary to do the job well. 

This concept of using properly trained managers should be in- 
corporated into the process of creating self-sustaining programs. 
In addition, it is necessary to set priorities regarding the allocation 
of scarce resources. It is better to use resources effectively and effi- 
ciently to do a few projects well than to spread the same resources 
over many projects in a restricted and inadequate manner. 

One must also be concerned with the quality of the outcome 
of the project. The outcome should represent excellence in achiev- 
ing the stated objectives. Evaluation will tell you whether you have 
delivered a quality service with constituent satisfaction. You should 
not settle for less. 

Finally, and most important, at all times we must maintain a 
customer-oriented service mentality. In a sense, those who are dis- 
abled are like hostages. They are held hostage to their disability and 
are held hostage to those of us who can help relieve their afflic- 
tion. Often they have few, if any, options in their quest for a better 
life. Accordingly, we must be especially conscious of the humani- 
tarian aspect of our actions. This feeling for humanity must per- 
vade our thinking, our planning, and our actions. 


This brief overview was developed from materials written by Mr. Alan W. Johns, 
Dr. Bjorn Thylefors, Sir John Wilson, and the author. 



Appendix G 

A Brief Review of Milestones in the 
Global Program for the Prevention 
of Blindness 

Compiled by Terrence Gillen 


1882 London Society for the Prevention of Blindness is established 
and begins focusing attention on the causes and prevention 
of blindness at an International Congress of Hygiene in 
Geneva. Interest in preventing blindness continues sporadically 
over the next several decades. 

1908 Christoffel-Blindenmission (CBM) is founded in Germany to 
provide education and rehabilitation of blind and other dis- 
abled people. 

The National Society to Prevent Blindness (NSPB) is founded 
in the United States. 

1915 The Permanent Blind Relief War Fund for Soldiers and Sailors 
of the Allies, Inc. is founded in Paris to aid blind Belgian 
soldiers and British war blind and to educate blinded French 
veterans. It evolves into the American Braille Press for War 
and Civilian Blind, Inc. (which produced 19 million pages of 
braille by 1927); the American Foundation for Overseas Blind, 
Inc.; and finally in 1977 Helen Keller International. 

1929 Twenty-eight nations are represented at an assembly at The 
Hague where ophthalmologists from Europe and the United 
States and the League des Societies de la Croix Rouge found 
the International Association for the Prevention of Blindness. 
Prof, de Lapersonne (France) and Dr. Park Lewis (USA) are 


375 


376 Appendix G 

elected President and Vice President. During its early years, 
the Association’s General Assembly is held in conjunction 
with the International Congress of Ophthalmology (ICO), 
generally with a half day devoted to the prevention of blind- 
ness. The Association introduces the Journal of Social Oph- 
thalmology , in French and English; 38 editions of this Journal 
are published until it is discontinued in 1967. 

The International Organization Against Trachoma is founded 
in France. 

1930 President Herbert Hoover invites 50 countries to participate 
in the World Conference on Work for the Blind, which is held 
in 1931 in Washington, D.C. 

1947 British Government’s Colonial Office White Paper addresses 
the general impression that there are an estimated 5 million 
blind people in the world, of whom 2 million live in India. 

1948 World Health Organization (WHO) is founded, but at first 
there are no specific activities in the field of blindness preven- 
tion. Trachoma is the first blinding disease to which WHO 
directs its attention; WHO initiates the gradual development 
of surveillance and control methodologies and research and 
field studies from the early 1950s. Mass treatment programs 
are subsequently successful in providing topical treatment with 
tetracycline, health education, and surgical correction of 
trichiasis. Some of these field research studies are developed 
into national trachoma control programs in many develop- 
ing countries in the 1950s and are the antecedents of today’s 
comprehensive national programs for the prevention of 
blindness. 

1950 British Empire Society for the Blind (subsequently called the 
Royal Commonwealth Society for the Blind) is founded in 
the United Kingdom and begins blindness surveys in Nigeria, 
Ghana, Sierra Leone, and in East and Central Africa. These 
surveys, which demonstrate a much greater prevalence than 
had been estimated, lead to a growing recognition of the 
magnitude of the problem and the need for making preven- 
tion a priority. 


Milestones 377 


1952 WHO convenes an Expert Committee on Trachoma. Subse- 
quent meetings are held in 1955 and 1961, and a Scientific 
Group meets in 1965. 

From 1952 through 1956 two teams, one ophthalmic and one 
entomological, appointed by the Royal Commonwealth 
Society for the Blind, survey the extent and consequences of 
onchocerciasis in West Africa and propose a control program. 

1960 The Association begins scheduling its General Assemblies to 
coincide with meetings of the newly formed European Con- 
gress of Ophthalmology. Sir Stuart Duke-Elder and Sir John 
Wilson propose cooperation between ophthalmologists and 
blind welfare workers. 

The Association agrees to work with WHO on a World Health 
Day for the prevention of blindness, scheduled for April 7, 
1962. 

1961 The International Eye Foundation is founded in the United 
States by John Harry King, Jr., M.D., whose primary pur- 
pose is teaching with a mandate of the prevention and cure 
of blindness worldwide. 

Christoffel-Blindenmission’s services are extended to include 
ophthalmological work, particularly curing and preventing 
blindness. 

1962 As Director of the Royal Commonwealth Society for the Blind 
and chairman of the Committee for the Prevention of Blind- 
ness of the World Council for the Welfare of the Blind 
(WCWB), Sir John Wilson proposes a fusion between the 
Committee and the Association for the Prevention of Blind- 
ness. Although these organizations remain independent, a 
Joint Committee is formed. 

1963 Operation Eyesight Universal is founded in Canada. 

1964 First meeting of Joint Committee in Geneva. 

Adoption of an international system for classifying the causes 
of blindness. This system is recommended for use worldwide 
by the Association and is subsequently published in the Jour- 
nal of Social Ophthalmology and is widely distributed. 


378 Appendix G 

1968 Although reporting of results is confused by different defini- 
tions of blindness and its causes, it is increasingly clear that 
besides trachoma there are several important blinding diseases 
commonly found in developing countries. 

1971 Prof. Michaelson arranges a seminar on blindness prevention 
in Jerusalem. The Executive Committee of the Association 
proposes expanding its General Assembly at the forthcoming 
International Congress of Ophthalmology to a two-day Con- 
ference on Blindness and Visual Impairment. 

The American Foundation for Overseas Blind (AFOB) pro- 
vides assistance to 103 countries, and teachers from 15 na- 
tions attend orientation and mobility courses for educators. 
With a new emphasis on blindness prevention, AFOB begins 
a worldwide campaign to prevent nutritional blindness. 

1972 Following a request from the World Health Assembly, WHO 
carries out a systematic inventory of available data on blind- 
ness and reports that there are between 10 and 15 million blind 
people in the world. 

A Study Group on the Prevention of Blindness is convened 
to assess the magnitude of the problem and elaborate upon 
the definitions of visual impairment and blindness (that are 
used internationally to this day). 

Vitamin A capsule distribution programs begin with laun- 
ching of initiatives in Indonesia and El Salvador. 

1974 At ICO meeting in Paris, changes to broaden the base of the 
Association are considered. WHO indicates the need for a 
single international agency uniting the many groups work- 
ing in the prevention of blindness field. After consultations 
between leaders of the Association and the WCWB, a plan 
to restructure the organization is developed to make it more 
effective in global blindness prevention. Sir John Wilson 
(United Kingdom) is elected President and an executive com- 
mittee is authorized to amend the Association’s constitution. 
The proposed changes are subsequently adopted. 

1975 A resolution is passed by the World Health Assembly request- 


Milestones 379 


ing the Director General to enlist support of member govern- 
ments in developing resources to prevent blindness and in 
setting up an advisory group. 

The World Health Assembly adopts a resolution requesting 
the Director-General to take action against the problem of 
blindness and to establish initiatives against trachoma, 
xerophthalmia, cataract, onchocerciasis, ocular trauma, and 
glaucoma. This resolution was to be the basis for the establish- 
ment of the WHO Program for the Prevention of Blindness 
in 1978. 

With the encouragement of WHO, the Association is 
transformed into the International Agency for the Prevention 
of Blindness (I APB) on January 1. The I APB’s charge is to 
lead a cooperative universal offensive to reduce drastically 
the world’s avoidable blindness by controlling major blinding 
diseases. The first priority of IAPB is the establishment of 
national prevention of blindness committees. Since its found- 
ing, the IAPB as a consortium of non-governmental organiza- 
tions (NGOs) and national committees within more than 60 
countries has directed efforts toward mobilizing resources, in- 
creasing public awareness, supporting sight conservation pro- 
grams, and implementing WHO health-care strategies aimed 
at blinding diseases. 

The Onchocerciasis (River Blindness) Control Program (OCP) 
is launched in originally 7 (and later 11) West African coun- 
tries with WHO as executive agency and support from the 
Food and Agriculture Organization, the United Nations 
Development Program, the World Bank, and a number of 
donor countries. 

A survey on nutritional blindness in Haiti determines that 
xerophthalmia is the leading cause of blindness in Haitian 
children. 

1976 WHO inter-regional meeting in Baghdad stimulates worldwide 
interest in the control of major causes of blindness. At this 
meeting are 27 participants from 21 countries, 27 observers, 
12 representatives of NGOs (most of which are affiliated with 
the IAPB), 7 WHO temporary advisors, and 7 WHO staff 
members. This largest gathering of experts on the prevention 


380 Appendix G 


of blindness ever assembled up to that time establishes 
strategies for manpower requirements and the development 
of eye-health services. 

The theme of World Health Day on April 7 is “Foresight 
Prevents Blindness.” 

The National Program for the Control of Blindness is 
launched in India — the first-ever comprehensive nationwide 
program for the prevention and control of blindness, and a 
forerunner of similar developments around the world. 

1978 WHO Program for the Prevention of Blindness is officially 
established in Geneva. The first advisory meeting on program 
development initiates a number of task-force meetings on 
specific issues, including data on blindness, manpower 
development, economics of blindness prevention, primary eye 
care, and national program development. 

WHO Task Force estimates that (according to which defini- 
tion of blindness is adopted) there are probably 28 to 42 
million blind people in the world. 

Seva Foundation is founded in the United States to apply 
lessons learned through smallpox eradication to alleviate suf- 
fering due to other public health problems. Blindness preven- 
tion in Nepal is adopted as primary focus of program activity. 

The First General Assembly of the IAPB is held in Oxford, 
United Kingdom, where 170 representatives from 44 nations 
convene for a three-day conference. Because it is already well 
known that mankind has the ability to significantly curtail 
the majority of the world’s blinding eye diseases and prevent 
at least half of all blindness through well-planned sight con- 
servation programs using available resources and medical 
knowledge, the theme of the Assembly is “Mobilizing Re- 
sources.” Representatives of the world’s blind population, 
organizations concerned with their welfare, government of- 
ficials, ophthalmologists, and experts in vision science and 
other scientific disciplines evaluate the state of knowledge in 
each major area of visual disability and blindness and examine 
the possibilities for treatment and prevention. Prospects for 
greatly increased blindness prevention activities are studied 


Milestones 381 


in relation to regional needs, thus enabling the participants 
to return to their homes resolved to stimulate governmental 
and inter-governmental action. 

1979 WHO Director-General establishes a WHO Program Advisory 
Group (PAG) on the prevention of blindness. Subsequent PAG 
meetings successfully evaluate progress made in the Program 
and coordinate work with the collaborating NGOs. 

Foresight (Australian Overseas Aid and Prevention of Blind- 
ness, Ltd.) is founded in Australia. 

WHO Task Force meets in Bethesda, Maryland. 

1980 Second PAG meets in Ouagadougou and adopts recommen- 
dations of WHO Task Force meeting in Bethesda. 

A network of 10 WHO Collaborating Centers for research 
and training in the prevention of blindness are identified over 
the first two years of the Program and agreements for designa- 
tion of those centers are elaborated. Another four centers have 
subsequently been included in this network. 

1981 An international conference at Leeds Castle, England, for- 
mulates global strategies for the prevention of disability 
leading to the formulation by three United Nations agencies 
of the International Initiative Against Avoidable Disablement, 
now known as the IMPACT program. 

First nationwide probability sample-based survey of blind- 
ness is carried out in Nepal with the cooperation of WHO, 
the government of the Netherlands, Seva Foundation, the 
Norwegian Agency for International Development, and other 
participating agencies. Results from the survey give the first 
indication that cataract accounts for two thirds of Nepal’s 
blindness. This survey forms the basis for the first five-year 
plan for the Nepal Blindness Program. 

1982 The Second General Assembly of the IAPB is held in 
Bethesda. This meeting of 300 people representing more than 
50 countries is by far the largest international gathering of 
experts on blindness prevention ever convened to that time. 
The theme “New Horizons in Sight” reflects the fact that 


382 Appendix G 

IAPB’s earliest goal — the creation of national committees for 
the prevention of blindness — had been almost fully achieved 
and that many of these committees had been successful in 
initiating national sight-conservation programs. Participants 
at this Assembly look for new horizons by discussing several 
ongoing or recently completed blindness prevention projects, 
assessing their results, and establishing the ones that are most 
successful as models for future efforts. This Assembly also 
conveys the message that well-designed blindness prevention 
programs — particularly those that draw exclusively on local 
resources — can be highly effective even when judged by 
economic as well as medical criteria. Dr. Carl Kupfer (USA) 
is elected President. 

A Regional Advisor for Prevention of Blindness is established 
in the WHO Regional Office for South-East Asia in New 
Delhi. This full-time position is co-funded by the Royal Com- 
monwealth Society for the Blind and the Asian Foundation 
for the Blind. 

Seva Service Society is founded in Canada to encourage 
broader participation by Canadian citizens in Seva’s blind- 
ness prevention and other activities. 

1983 Organisation pour la Prevention de la Cecite (OPC) is founded 
in France. 

1985 The International Eye Foundation becomes the first interna- 
tional eye-care NGO to be accepted into official relations with 
WHO. 

1986 The Consultative Group of NGOs to the WHO Program for 
the Prevention of Blindness is established to provide a forum 
for closer consultation among organizations interested in 
prevention of blindness. Meetings are to take place on years 
when the Program Advisory Group does not meet. Meetings 
of the Consultative Group also provide an opportunity for 
communicating to interested NGOs particular projects or 
needs in selected countries, where the WHO Program does 
not have the required resources to intervene, but where NGOs 
have good working channels. Mr. Alan W. Johns is elected 
first Chairman of the Group. 


Milestones 383 


The Third General Assembly of the IAPB is held in New 
Delhi, India. This Assembly is attended by over 400 ophthal- 
mologists, eye-care professionals, public health specialists, 
managers, and others engaged in the battle against unneces- 
sary blindness. Its theme “A Decade of Progress” coincides 
with the completion of 10 years of IAPB service. Participants 
discuss possible means of strengthening national blindness 
prevention committees and ways of improving communica- 
tion and cooperation among national committees and NGOs. 
Four workshops are held and four symposia examine the 
operation and delivery of eye-care services, communication 
for eye-health care, the magnitude of blindness, and com- 
munity ophthalmology. A course in research methodology in 
public health and clinical ophthalmology is presented. Dr. 
Kupfer is re-elected President. 

Helen Keller International announces a global attack on 
cataracts. 

1987 WHO Task Force completes a second comprehensive compi- 
lation and analysis of blindness data, and estimates that there 
are between 27 and 35 million blind people in the world. 

1989 IAPB hosts a four-day series of conferences in Bethesda, 
Maryland, at which 70 people from more than 20 countries 
participate. IAPB commemorates the tenth anniversary of the 
WHO Prevention of Blindness Program and with major 
NGOs holds a symposium on the control of cataract blind- 
ness. These meetings provide the participants an opportun- 
ity to discuss accomplishments in the prevention of blindness 
field and to examine the delivery of eye care relevant to the 
alleviation of cataract blindness. They also present a valuable 
opportunity to discuss program and organizational issues and 
enable a rich exchange of ideas on a variety of topics, includ- 
ing program strategies, training and educational modalities, 
evaluation methodologies, cost-recovery mechanisms for eye- 
care programs, and applications of appropriate technologies. 

1990 The Fourth General Assembly of the IAPB is held in Nairobi, 
Kenya, and is attended by more than 400 ophthalmologists, 
public health workers, and managers. National prevention of 


384 Appendix G 


blindness committees from 60 countries are represented by 
113 people at the Business Meeting. The theme “Sustainable 
Strategies— Agenda for the 1990s” is discussed at six plenary 
sessions and four workshops by 86 designated speakers and 
panelists, plus scores of active participants. The contingent 
from Francophone Africa is provided with simultaneous 
translation at all plenary sessions, and several workshops are 
held in French. During the five-day meeting, the following 
subjects are discussed at the plenary sessions: national 
programs in Africa, regional progress reports, sustainable 
manpower development for blindness prevention, new 
developments in the control of major causes of blindness, and 
sustainable national program development. The workshop 
topics include: manpower development, delivery of specific 
eye-care services, major challenges and priorities for the 
delivery of eye-care services, and essential characteristics of 
a model self-sustaining prevention of blindness program, in- 
cluding partners such as private industry, NGOs, and WHO. 
Mr. Alan W. Johns (United Kingdom) is elected President. 

Christoffel-Blindenmission and Sight Savers co-fund a land- 
mark WHO meeting in London on childhood blindness. 

1991 A Regional Advisor for Prevention of Blindness is established 
in the WHO Regional Office for the Americas. Co-funding 
for this post is provided by Sight Savers and Organization 
Nacional de Ciegos de Espana. Similarly, the WHO Preven- 
tion of Blindness headquarters staff are strengthened by a 
post supported by the International Association of Lions 
Clubs. 

Ongoing evaluation of the very successful vector control 
scheme of the Onchocerciasis Control Program, which has 
been applied over more than 1 million square kilometers. The 
disease and its eye complications are now about to disappear 
in the program area. In addition, several IAPB member 
organizations are increasingly involved in Ivermectin distribu- 
tion programs in the extension program areas. 

A meeting on strategies for Ivermectin distribution through 
primary health-care systems is held at WHO headquarters in 


Milestones 385 


Geneva, with support from the Consultative Group of NGOs 
to the WHO Program for the Prevention of Blindness. 

The Second Leeds Castle International Conference on the 
Prevention of Disability proposes an agenda of action against 
avoidable disability using the Prevention of Blindness pro- 
gram as its model. 


If you wish to comment upon or make suggestions to these brief “milestones,” 
please write to Terrence Gillen, National Eye Institute, National Institutes of 
Health, Bldg. 31, Rm. 6A-17, Bethesda, Maryland 20892, USA. 
















. 











































PART 11 


Index 


WORLD BLINDNESS AND 
ITS PREVENTION 
VOLUME 4 





Index 


Abiose, Adenike 181, 187, 333, 343 
Adala, Henry S. 3, 343 
Afghanistan 339 
Agaba, Lincoln 221 
Ahuja, Suresh C. 343 
Al-Ghanim, Sheikh Abdullah M. 67, 

334, 342, 343 

Al-Majid, Saleh Abdullah 334 
Albania 339 
Alcon Foundation xvi, 3 
Algeria 339 

Allergan International xvi, 3 
American Academy of Ophthalmology 
(AAO) 66 

American Optometric Association 
(AOA) 66 

Angola 45, 115, 339 
Antigua 339 

appropriate technology 22, 211, 218, 227, 
258, 285, 286, 362, 366 
Arab Gulf Fund for the United Nations 
Development Organization 
(AGFUND) 56, 367 
Aravind Eye Hospital 82, 126, 162, 
164-167, 169, 170, 280-282, 285, 286, 
372 

Argentina 55-58, 339 

amblyopia 60 

Aurell, Elisabeth 334 

Australia 101-105, 111, 112, 231, 332, 

340, 343, 369, 381 
Austria 339 
Auzemery, A. 332 
Ayed, S. 337 

Bado, Moussa 333 
Badr, Ihsan A. 337, 343 
Bahamas 339 
Bahrain 71, 339 

Bamako 39, 40, 51, 187, 245, 336, 372 
Bangladesh 79-81, 97, 98, 119, 327, 332, 
340, 343 


Bao-chen, Sun 332, 343 
Barbados 339 
Barbuda 339 

Barros, O. Monteiro de 337 

Begum Raushan Ershad 332 

Beijing Institute of Ophthalmology 105, 

338 

Belarus 339 
Belgium 332, 339, 343 
Belize 59, 63, 64, 339 
Beltranena, Fernando 59, 61, 333, 336, 
342, 343 
Benin 37, 339 
Bhutan 79, 81, 340 
Billson, Frank 101, 332, 341, 342 
Blyth, David 343 
Bolivia 53, 339 

Botswana 27, 35, 37, 38, 45-47, 332, 

339 

Boyce, Virginia 65, 341, 342 
Brazil 54, 56, 57, 253, 332, 337, 339 
British Council for the Prevention of 
Blindness 77, 186, 231 
Brunei Darussalem 340 
Bulgaria 339 

Burkina Faso 37, 38, 51, 332, 339 
Burma (see Myanmar) 

Burundi 35, 37, 39, 339 

Cameroon 50, 51, 182, 332, 339 
Canada 13, 46, 65, 66, 230, 235, 262, 
332, 339, 369, 377, 382 
Cape Verde 339 
Carey, Kevin 223, 249, 259, 321 
cataract xvii, 12, 14, 27, 28, 30, 32-34, 
45, 49, 50, 53, 54, 57, 60, 65, 66, 69, 
72, 73, 77, 79, 80, 83, 85-90, 92, 
95-97, 101-103, 105-111, 116-121, 125, 
126, 128, 129, 149, 150-155, 157-159, 
161-170, 194, 195, 199, 205, 209, 217, 
224, 227, 228, 230, 231, 233, 243, 253, 
255, 262, 267, 279-281, 283, 


389 


390 Index 


cataract (cont.) 

285-287, 289-291, 297, 305, 306, 
309-312, 315-318, 320, 326, 359, 
361-368, 370, 372, 379, 381, 383 
Cataract-Free Zone 53, 54, 57, 83, 89, 
152, 199, 253, 326, 364 
Central Africa 27, 31, 194, 376 
Central African Republic 35, 37, 40, 50, 

332, 339 

Central America 59, 62, 63, 253 
Chad 35, 38, 40, 50, 51, 339 
Chandra, Suresh 334 
Chibret International (Ophthalmic Group 
of Merck Sharp & Dohme) xvi, 3, 58, 
61 

Chile 55-58, 332, 339, 343 
China 101, 105, 106, 202, 203, 255, 296, 
326, 332, 338, 340, 343, 361, 362 
Chirambo, Moses C. 15, 27, 45, 123, 

326, 333, 341, 342 
Chovet, Marcel 77, 332, 342, 343 
Christoffel-Blindenmission (CBM) 13, 

28, 46, 51, 53, 57, 62, 64, 66, 77, 83, 
95, 102-104, 107, 222, 231, 249, 250, 
257, 344, 369, 370, 375, 377, 384 
Ciba-Geigy Corporation 61, 64 
Clemmesen, Viggo 325 
Colombia 53, 57, 63, 332, 339 
community ophthalmology 82, 99, 116, 
119-121, 128, 326, 327, 366, 382 
Comoros 339 

congenital disorders 73, 108, 109 
Congo 35, 37, 39, 50, 335, 339, 366 
Consultative Group of NGOs to the 
WHO Program for the Prevention of 
Blindness 9, 10, 46, 250, 251, 341, 

369, 382, 385 

Contreras, Francisco 53, 199, 237, 326, 

333, 336, 341, 342 
Cook Islands 103, 104, 340 

corneal problems 32, 47, 60, 69, 72, 73, 
80, 81, 84, 86, 90, 93, 96, 97, 108, 110, 
111, 153, 171, 190, 194-196, 227, 291, 
306, 310, 312 
Costa Rica 59, 339 
Cuba 339 
Cyprus 339 
Czechoslovakia 339 

Dadzie, K.Y. 186, 189, 343 
Dawson, Chandler R. 337 
Delgado, Alzira Nicolini 332 
Denmark 325, 332, 335, 339 


De Sole, G. 186, 189 
developmental disorders 108, 109 
diabetes 65, 77, 92, 93, 151, 268, 270 
diabetic retinopathy 57, 65, 77, 79, 109, 
154, 319 

Diallo, Joseph S. 186, 334, 342, 343 

Djibouti 339 

Dominica 339 

Dominican Republic 339 

Drummond, Michael F. 157-159, 161, 169 

Dunsford, Michael A. 261 

Durango, Delia 343 

East Africa 9, 31, 34, 47, 50, 117, 136, 
193, 194, 202, 254 

Eastern Mediterranean 67, 69-71, 335, 
337, 339, 342 

Ecuador 53, 57, 60, 61, 63, 339, 343 
education (also see training) 8, 13, 21, 

29, 32, 38, 47, 55, 68, 74, 80, 81, 86, 
88, 92, 93, 96, 99, 104, 109, 123, 
126-128, 130-132, 150, 172, 173, 197, 
209-214, 216, 231, 237, 245, 246, 250, 
251, 255, 261, 263, 265, 266, 275-277, 
304, 305, 309-311, 313, 316, 321, 322, 
325, 327, 359, 365, 375, 376, 383 
Egypt 68, 71, 194, 335, 339 
El Salvador 59, 63, 339, 378 
El-Gorafi, Ibrahim 334 
Elsheikh, Hadi 334 
Emhart, Rene Canovas 332 
epidemiology 37, 38, 54, 56, 57, 62, 77, 
78, 82, 111, 116, 123, 131, 133, 149, 

154, 169, 181, 183, 184, 186, 191, 194, 
205, 211, 244-246, 368 
Equatorial Guinea 37, 339 
Estonia 339 
Etya’ale, Daniel 49 

Europe 10, 15, 59, 77, 78, 85, 115, 116, 
335, 375 

Expanded Program on Immunization 
(EPI) 173, 310, 316 
eyeglasses ( see spectacles) 

Faal, Hannah B. 31, 153, 332, 343 
Fiji 102, 105, 340 
Finland 339 

Foresight 102-104, 344, 369, 381 
Foot, Oliver 334 
Foster, Allen 115, 153, 173, 318 
France 77, 332, 339, 369, 375, 376, 382 

Gabon 35, 37, 50, 339 
Gallagher, William 343 


Index 391 


Galvis, Virgilio 332 
Gambia 28, 31-34, 38, 47, 50, 51, 149, 
153, 332, 339, 343 
Garms, Christian 341 
Germany 13, 77, 230, 332, 339, 369, 375 
Ghana 27, 28, 38-40, 46, 50, 51, 115, 

117, 124, 189, 332, 339, 376 
Gikonyo, A.K. xix, 3, 333 
Gilbert, Suzanne 334 
Gillen, Terrence iii, 375 
glasses (. see spectacles) 
glaucoma 12, 27, 36, 45, 50, 57, 60, 65, 
69, 72, 73, 77, 79-81, 85, 86, 92, 93, 
96, 97, 108-111, 119, 126, 154, 195, 

205, 206, 208, 209, 228, 243, 262, 267, 
291, 310, 313, 359, 379 
Gmiinder, J. 275 
Goldschmidt, Ernst 332 
Greece 339 
Grenada 339 

Guatemala 59-64, 333, 336, 339, 343 

Guinea 37, 102, 103, 333, 339, 340, 343 

Guinea-Bissau 339 

Gupta, K.S. 233, 267 

Guramatunhu, S. 334 

Guyana 339 

Hagan, Maria 332 
Haiti 260, 339, 379 
Hamurwono, Bambang 333 
Hardenberg, A. 253 

Helen Keller International (HKI) 28-30, 
47, 53, 57, 66, 95, 102-104, 170, 199, 
200, 202, 238, 249, 250, 257-259, 344, 
369, 370, 375, 383 
Herbecq, Jean-Paul 332, 343 
Hoffmann-La Roche and Co., E xvi, 3, 275 
Honduras 59, 63, 64, 339 
Horton, Aveline 334 
Hu, Cheng 326, 332, 343 
Huguet, Pierre 332 
Hui, Lim Kuang 101, 334, 342 
Hungary 339 

Husain, Rabiul 119, 327, 332, 342, 343 

IAPB News 30, 169, 295, 364 
Ibrahim, U.F. 333 
Iceland 339 

India 11, 70, 79-82, 85-88, 90, 91, 93, 

94, 96-99, 126, 130, 149, 151, 154, 155, 
162, 163, 165, 169, 172, 202, 203, 
233-236, 255, 267, 268, 274, 279, 281, 
285-287, 304, 325, 333, 335, 338, 340, 
343, 361, 362, 372, 376, 380, 383, 385 


Indonesia 79-81, 83, 110, 171, 172, 333, 
340, 378 

Institut d’Ophtalmologie tropicale de 
l’Afrique (Institute of Tropical 
Ophthalmology in Bamako — 

IOTA) 39, 40, 245, 336, 372 
International Agency for the Prevention 
of Blindness (IAPB) v, xv, xvii, 3-5, 
7-11, 15-18, 28, 30, 43, 46, 53, 55, 67, 
70, 71, 78, 81, 98, 136, 152, 169, 201, 
203, 247, 250, 293, 295, 296, 299, 304, 
309, 314, 325, 326, 331, 339, 341, 345, 
359, 360, 363, 364, 367-372, 

379-384 

International Association for the Preven- 
tion of Blindness 7, 345, 347, 375 
International Center for Epidemiologic 
and Preventive Ophthalmology 
(ICEPO) 66, 116, 245, 336 
International Centre for Eye Health 
(ICEH) 34, 77, 116, 196, 245, 337 
International Council of Ophthalmology 
(ICO, the executive body of the 
International Federation of Ophthal- 
mological Societies — IFOS) 7, 353, 
354, 364, 378 

International Eye Foundation (IEF) 9, 
28-30, 53, 61, 63, 66, 249, 250, 257, 
262, 344, 369, 370, 377, 382 
International Federation of 

Ophthalmological Societies (IFOS) 7, 
8, 343, 347 

International Organization Against 
Trachoma 376 

International Vitamin A Consultative 
Group (IVACG) 47, 66, 174 
intraocular hypertension 206-208 
intraocular lenses (IOLs) 83, 120, 
162-164, 168, 169, 280, 312, 364 
Iran 339 
Iraq 68, 339 
Ireland 339 
iridotomy 206-208 
Israel 304, 333, 339 
Istiantoro, Dr. 333 
Italy 150, 339 

Ivermectin 50, 60, 61, 64, 77, 181-187, 
189-191, 254, 255, 260, 310, 320, 384 
Ivory Coast 115, 339 
Iwahashi, Akiko 343 

Jamaica 260, 339, 343 
Jana, Walter 334 


392 Index 


Japan 101, 111, 112, 230, 333, 338, 340, 
343, 367 

Jenkyns, A.T. 273, 332, 341 
Johns, Alan W. xv, 9, 223, 299, 334, 

341, 360, 373, 382, 384 

Johns Hopkins School of Hygiene and 
Public Health 66, 116, 245, 336 
Johnson, Gordon J. 149, 303, 334, 337, 343 
Jones, Barrie R. 185, 187, 344 
Jordan 68, 71, 339 
Jose, R. 333 

Juntendo University School of 
Medicine 82, 338 

Kagame, K. 41 
Kampuchea 340 
Kanai, Atushi 333, 338 
Katenga, S.B. 334 

Kenya xv, xix, 4, 5, 9-16, 28, 38, 45, 46, 
67, 77, 115, 117, 124, 135-137, 139, 

140, 193-196, 261-265, 273, 308, 333, 
339, 343, 383 

keratomalacia 108, 110, 171, 177 
Khan, Daud M. 342 
Khazraji, Youssef Chami 333 
Khosla, P.K. 126, 338 
Kibaki, Mwai xv, 5, 7, 11, 15 
Kinabo, N.N. 334 

King Khalid Eye Specialist Hospital 72, 
74, 337 

Kiribati 103, 104, 340 
Klauss, Volker 332, 342 
Konate, Ismaila 327, 333 
Konyama, Kazuichi 82, 101, 112, 333, 

342, 343 

Korea 101, 106, 340 
Kothari, Gopa 209 

Kupfer, Carl iii, xvi, xvii, 3, 5, 7, 15, 56, 
57, 67, 85, 169, 295, 299, 336, 341, 

342, 361, 382, 383 
Kuwait 339 

Lakhey, S.P. 333 

Lao People’s Democratic Republic 
(Laos) 333, 340, 367 
lasers 84, 166, 205-208 
Latin America 35, 53, 54, 56, 57, 60, 61, 
85, 152, 199, 253, 254, 276, 326, 341, 363 
Latvia 339 
Lebanon 339 
leprosy 32, 209, 314 
Lesotho 27, 35, 37, 38, 45-47, 124, 307, 
333, 339 


Liberia 182, 339 
Libya 339 

Lions Clubs 57, 235, 238, 262, 281, 287, 
295, 371, 384 
Lim, A.S.M. 112, 343 
Lithuania 339 
Lloyd, Meredith 334 
Lo, Wenbin 332 
Lorenzen, Ute 4 
Luxembourg 339 

Mabrouk, Ridha 342 
Madagascar 333, 339 
Maichuk, Y.F. 338, 342 
Majekodumni, A.A. 333 
Makhwade, Kealeboga 332 
Malawi 28, 32, 37, 38, 45, 46, 117, 124, 
194, 307, 326, 333, 339, 372 
Malaysia 101, 109, 110, 340 
Maldives 79, 81, 340 
Mali 28, 38, 39, 50, 51, 115, 117, 187, 
245, 327, 333, 336, 339, 372 
Malik, S.R.K. 80, 85, 333, 342, 343 
Malta 339 
Martin, Elvira 334 
Martinez, Antonio 334 
Matin, M.A. 332 
Maul, Eugenio 55, 332, 342, 343 
Mauritania 38, 39, 339 
Mauritius 339 
McManus, Maureen 332 
McMoli, Theodosia E. 332 
measles 27, 171, 173, 174, 177, 209, 262, 
310 

Mectizan 61, 183 
Mectizan Expert Committee 183 
Memon, Shahid Ahmed 343 
Merck Sharp & Dohme xvi, 3, 58 
Mexico 57, 60, 339 
Mindolo, William 334 
Mireilli, Rakotomalala 333 
Mohammed, K. 334 
Mohan, Madan 126, 154, 343 
Mokete, Musi 333 
Monaco 339 
Mondaca, Rafael 334 
Mongolia 79-81, 340 
Morocco 194, 333, 339 
Mortimer, C. 343 

Mozambique 35, 37, 40, 45-47, 333, 339 
Mushega, K. 334 
Mwandu, David 334 


Index 393 


Myanmar (Burma) 79-81, 83, 205, 206, 
208, 333, 340 
Myaw, Tun Aung 333 
myopia 77, 109 

Nakajima, Akira 7, 30, 82, 112, 277, 

333, 341 

National Eye Institute (Bethesda, 
Maryland) 3, 15, 57, 66, 152, 162, 

170, 179, 299, 336, 364, 368, 372 
National Society to Prevent 
Blindness 375 
Negrel, A.D. 243 

Nepal 79-81, 125-128, 230, 152, 225, 
228-231, 255, 333, 340, 366, 380, 381 
Nepal Netra Jyoti Sangh 127, 366 
Netherlands 262, 333, 339, 381 
New Zealand 101, 102, 104, 111, 112, 340 
Newland, Henry S. 112, 205, 332 
Nicaragua 59, 63, 339 
Niger 37, 38, 40, 187, 339 
Nigeria 28, 38, 115, 116, 139, 181-187, 
333, 339, 343, 376 
North Africa 193, 194 
North America 65, 66, 85, 115, 342 
Norway 153, 333, 339 
Norwegian Association of the Blind and 
Partially Sighted 344 
Nowill, Dorina de Gouvea 343 

Obowu, Chito 333 
Oceania ( see South Pacific) 

Oman 339 

onchocerciasis (river blindness) xvii, 27, 
35, 37, 41, 49, 50, 60, 61, 68, 69, 77, 
85, 181-187, 189, 190, 209, 224, 243, 254, 
260, 308, 310, 359, 363, 365, 377, 379, 384 
Operation Eyesight Universal (OEU) 13, 
28, 53, 54, 95, 199, 235, 238, 249, 257, 
262, 273, 344, 369, 370, 377 
operations research 24, 54, 57, 130-133, 
152, 246, 364, 372 
optic atrophy 108, 109, 111 
optometry 38, 66, 305, 313 
Organisation pour la Prevention de la 
Cecite (OPC) 77, 249, 257, 344, 369, 382 
Otoo, J.D. 332 
Otterlei, Oddvar 333 

Pakistan 97, 98, 285, 333, 339 
Palmer, John M., Ill 65, 257, 342 


Pan-American Association of 

Ophthalmology (PAAO) 53, 54, 57, 

66, 326 

Pan American Health Organization 
(PAHO) 55, 56, 335 
Panama 59, 339 
Panda, Anita 333 

Papua New Guinea 102, 103, 333, 340, 
343 

Paraan, Ronaldo A. 333 
Paraguay 55-58, 339 
Pararajasegaram, R. xv, 79, 126, 289, 
300, 341 

Partnership Committee (of International 
NGOs) 250, 251, 260, 354, 369 
Paswa, David 4 
Perera, M.R.L. 334 

Peru 53, 54, 57, 199, 237, 253, 326, 333, 
336, 339 

Phalakornkule, Suchint 334 

Philippines 101, 108, 333, 335, 340 

Pirie, Antoinette 325 

Pokharel, G.P. 125 

Pokhrel, R.P. 225, 333, 342, 344 

Poland 339 

Portugal 339 

Program Advisory Group (PAG) to the 
WHO Program for the Prevention of 
Blindness 250, 251, 295, 369, 380, 382 
Project Orbis 53, 54, 64, 66, 238, 344 

Qatar 68, 339 
Quana’a, Pawlos 29, 332 
Quequiner, Patrick 318 

Rajendra Prasad Centre for Ophthalmic 
Sciences, Dr. 86, 338 
Rathabaneng, F. 333 
Reddy, P. Siva 333, 341 
rehabilitation 55, 68, 94, 108, 110, 112, 
120, 171, 199, 237, 247, 250, 251, 257, 
261, 263, 265, 266, 287, 321, 375 
refractive errors 60, 69, 72, 73 
Remme, J. 186, 189 
Resnikoff, Serge 332, 336 
retinal disorders 57, 60, 65, 79, 109-111 
river blindness (see onchocerciasis) 

River Blindness Foundation 66 
Rodolfo Robles V Eye and Ear Hospital, 
Dr. 60-64, 336 
Romania 339 

Rotary Clubs 235, 238, 281 


394 Index 


Royal Commonwealth Society for the 
Blind (RCSB, also see Sight 
Savers) 13, 34, 80, 88, 103, 223, 261, 
262, 273, 369, 376, 377, 382 
Russia 338, 339 
Rwanda 339 

Sahel 36, 182 
Samoa 340 
San Marino 340 
Sanitprachakorn, Phanom 342 
Sao Tome and Principe 339 
Saudi Arabia 68, 69, 71-74, 334, 337, 339 
Sayek, Fiisun 239, 334, 343 
Seimon, Reggie 343 
Senegal 38, 115, 334, 339 
Senju Pharmaceutical Co., Ltd. xvi, 3 
Seva Foundation 66, 82, 95, 125, 127, 
230, 231, 344, 369, 370, 380-382 
Seychelles 339 
Shah, Ashok K. 4, 333 
Sheffield, Victoria M. 215, 309 
Shilkey, Mohamed A. 334 
Siddique, Abu Baker 332 
Sierra Leone 27, 28, 50, 51, 117, 124, 

182, 186, 334, 339, 376 
Sight and Life 3, 275, 276 
Sight by Wings 262 
SightFirst Program 57, 295, 371 
Sight Savers ( also see Royal 

Commonwealth Society for the Blind) 
13, 28, 34, 46, 66, 77, 88, 95, 98, 
102-104, 110, 186, 222, 249, 250, 257, 
261, 344, 369, 370, 384 
Singapore 98, 101, 108, 109, 111, 112, 

334, 340 
Sithole, W. 334 

social marketing 129-131, 209, 212-214, 
217, 282 

Soloman Islands 340 
Somalia 194, 334, 339 
Sommer, Alfred 170, 171, 173, 175, 334, 
336, 344 

Sonntag, Franz 343 
South Africa 115, 116, 174, 339 
South America 53, 55, 58, 59, 253, 342 
South-East Asia 79-81, 83, 97, 255, 290, 
327, 335, 338, 340, 342, 382 
Southern Africa 28, 35, 36, 45, 46, 118, 
136, 326 

South Pacific (Oceania) 101-104, 112 
Spain 334, 340 


spectacles (eyeglasses, glasses) 22, 33, 

54, 57, 80, 83, 128, 152, 165, 167, 
199-203, 222, 224, 228, 229, 246, 269, 
272, 280, 286, 314, 318, 364, 368 
Sri Lanka 79, 81, 83, 97, 98, 334, 340, 
343 

St. Christopher and Nevis 339 
St. Lucia 339 

St. Vincent and The Grenadines 339 
Stahl, Molina de 343 
Stilma, J.S. 186, 333 
Stolper, Horst 343 
Streets, Paul 4, 223 

Sudan 115, 117, 182, 194, 307, 334, 339 
Surinam 339 

Swaziland 27, 35, 37, 38, 45-47, 339 

Sweden 334, 340 

Switzerland 61, 340 

Sylla, Adiatou 333 

Syrian Arab Republic (Syria) 71, 339 

Tanzania 9, 27, 28, 38, 39, 45-47, 115, 
117, 124, 137, 173, 194, 308, 334, 339 
Tapsoba, Virginie 332 
Taylor, Hugh 112, 154, 332, 343 
Taylor, Joseph 9, 201, 344 
Tewari, H.K. 333 

Thailand 79, 81, 82, 108, 111, 178, 334, 340 
Thinasiaghe, Tilak 334 
Thulasiraj, R.D. 129, 169, 170, 172, 174 
Thylefors, Bjorn xv, 17, 315, 344, 365, 373 
Togo 35, 37, 39, 46, 50, 115, 339 
Tonga 102-104, 340 
Tororei, Samuel K. 4, 5, 15, 135, 333, 
342, 343 

Toufic, Nicolas 49, 51 
Trabelsi, Ahmed 334, 343 
trachoma xvii, 12, 27, 32, 33, 35, 45, 50, 
60, 62, 64, 68, 69, 71-74, 80, 85, 86, 
101, 105, 110, 126, 127, 193-197, 209, 
217, 224, 230, 239, 240, 243, 262, 279, 
291, 311, 312, 344, 363, 365, 368, 370, 
376-379 

training ( also see education) 8, 13, 21, 

22, 27-34, 36, 38-41, 45-47, 50, 51, 

53, 56, 63, 72, 77, 81-83, 87, 95, 98, 
102-104, 106, 108, 112, 115-121, 123, 
124, 126-133, 142, 143, 165, 183, 185, 
186, 200, 213, 215-217, 222, 223, 225, 
229-231, 240, 243, 245, 246, 254, 255, 
258, 262, 263, 265, 266, 275, 276, 
279-281, 296, 303-308, 315-320, 326, 
327, 362, 366-370, 372, 381, 383 


Index 395 


trauma 12, 27, 58, 69, 77, 80, 109, 119, 
209, 243, 313, 379 
Trinidad and Tobago 339 
Tukai, T. 35 

Tunisia 47, 68, 334, 337, 339, 343 
Turkey 239, 334, 340, 343, 366 

Udomkesmalee, Emorn 177, 334 
Uganda 27, 28, 38-42, 45, 46, 117, 124, 
137, 194, 222, 304, 334, 339 
Ukraine 340 

Underwood, Barbara A: 171, 175, 334 
UNICEF 62, 80, 92, 173, 371 
United Arab Emirates 339 
United Kingdom (UK) 11, 13, 77, 159, 
161, 245, 334, 337, 340, 343, 360, 369, 
376, 378, 380, 384 

United Nations (UN) 15, 16, 18, 136, 
247, 346, 367, 381 

United Nations Development Program 
(UNDP) 80, 83, 186, 367, 371, 379 
United States of America (USA) 11, 56, 
65, 66, 150, 151, 153, 174, 200, 201, 
231, 245, 262, 286, 299, 334-337, 339, 
369, 375-377, 380-382 
Uruguay 55, 57, 58, 339 

Vanuatu 103, 104, 340 
Vasquez, Rosa Amalia de 333 
Vassileva, Petja 342 
Venezuela 53, 57, 60, 339 
Venkataswamy, G. 170, 279, 285, 333, 
344 

Vietnam 101, 107, 340, 367 
Visonnavong, Vithoune 333 
vitamin A deficiency 27, 29, 36, 47, 50, 
54, 62, 63, 66, 84, 86, 91, 107, 108, 
171-174, 177-179, 209, 217, 218, 230, 
254, 255, 275, 276, 279, 287, 306, 310, 
312, 325, 364, 365, 367, 370, 378 
Vyas, Rajendra 80, 97, 112, 343 

Walia, D.S. 4 
Wania, Jamshed 333 
Watson, Duncan 341 


West Africa 31, 34, 35, 49-51, 118, 
181-186, 189, 190, 254, 377, 379 
Western Pacific 101, 102, 110-112, 335, 
338, 340, 342 
Whitfield, Randy 223 
Williams, D. 334 
Williams, Wilburt 343 
Wilson, Lady 334 

Wilson, Sir John 7, 334, 341, 344, 363, 
373, 377, 378 
Wilson, Lady 334 
World Bank 186, 379 
World Blind Union (WBU) 7, 71, 251, 
327, 341, 343, 347, 354 
World Health Organization (WHO) xv, 
xvii, 3, 5, 7, 9, 17, 18, 20-24, 27, 28, 
32-41, 46, 60, 62, 66, 70, 71, 74, 
79-83, 87, 94-97, 101, 103, 105, 107, 
108, 110, 112, 115, 116, 125, 136, 171, 
173, 183, 186, 202, 203, 205, 210, 215, 
222, 224, 231, 243-247, 250, 255, 260, 
275, 277, 279, 295, 296, 299, 303, 311, 
312, 335, 336, 339, 362-373, 

376-384 

xerophthalmia xvii, 12, 45, 47, 80, 85, 
126, 127, 171, 177, 217, 218, 243, 254, 
262, 275, 276, 291, 310, 363, 364, 368, 
379 

Yaminao, Bage 112, 333, 343 
Yanashima, Kenji 333 
Yanko, Lutza 333 
Yemen 334, 339 
Yeelen 51 
Yugoslavia 340 

Zaire 35, 37, 38, 50, 51, 115, 173, 339 
Zambia 27, 37, 38-40, 45-47, 140, 194, 
334, 339 

Zambujo, Yolanda T.D.C. 333 
Zhang, Shi-Yuan 338 
Zhang, Zikuan 332 
Zimbabwe 28, 37, 38, 45, 46, 115, 116, 
124, 194, 304, 307, 334, 339